4a - CVA (Stroke)
3. Which client would the nurse identify as being *most at risk* for experiencing a CVA? 1. A 55-year-old African American male. 2. An 84-year-old Japanese female. 3. A 67-year-old Caucasian male. 4. A 39-year-old pregnant female.
*1. African Americans have twice the rate of CVAs as Caucasians and men have a higher incidence than women; African Americans suffer more extensive damage from a CVA than do people of other cultural groups.* 2. Females are less likely to have a CVA than males, but advanced age does increase the risk for CVA. The Asian population has a lower risk, possibly as a result of their relatively high intake of omega-3 fatty acids, antioxidants found in fish. 3. Caucasians have a lower risk of CVA than do African Americans, Hispanics, and Native Pacific Islanders. 4. Pregnancy is a minimal risk for having a CVA.
4. The client diagnosed with a right-sided cerebrovascular accident is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? *Select all that apply.* 1. Position the client to prevent shoulder adduction. 2. Turn and reposition the client every shift. 3. Encourage the client to move the affected side. 4. Perform quadriceps exercises three (3) times a day. 5. Instruct the client to hold the fingers in a fist.
*1. Placing a small pillow under the shoulder will prevent the shoulder from adducting toward the chest and developing a contracture.* 2. The client should be repositioned at least every two (2) hours to prevent contractures, pneumonia, skin breakdown, and other complications of immobility. *3. The client should not ignore the paralyzed side, and the nurse must encourage the client to move it as much as possible.* 4. These exercises are recommended, but they must be done at least five (5) times a day for ten (10) minutes to help strengthen the muscles for walking. 5. The fingers are positioned so that they are barely flexed to help prevent contracture of the hand. TEST-TAKING HINT: Be sure to look at the intervals of time for any intervention; note that "every shift" and "three times a day" are not appropriate time intervals for this client.
12. A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement? 1. Administer a stool softener b.i.d. 2. Encourage the client to cough hourly. 3. Monitor neurological status every shift. 4. Maintain the dopamine drip to keep BP at 160/90.
*1. The client is at risk for increased intracranial pressure whenever performing the Valsalva maneuver, which will occur when straining during defecation. Therefore stool softeners would be appropriate.* 2. Coughing increases intracranial pressure and is discouraged for any client who has had a craniotomy. The client is encouraged to turn and breathe deeply, but not to cough. 3. Monitoring the neurological status is appropriate for this client, but it should be done much more frequently than every shift. 4. Dopamine is used to increase blood pressure or to maintain renal perfusion, and a BP of 160/90 is too high for this client.
7. The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? 1. An oral anticoagulant medication. 2. A beta blocker medication. 3. An anti-hyperuricemic medication. 4. A thrombolytic medication.
*1. The nurse would anticipate an oral anticoagulant, warfarin (Coumadin), to be prescribed to help prevent thrombi formation in the atria secondary to atrial fibrillation. The thrombi can become embolic and may cause a TIA or CVA (stroke).* 2. Beta blockers slow the heart rate and decrease blood pressure but would not be an anticipated medication to help prevent a TIA secondary to atrial fibrillation. 3. An anti-hyperuricemic medication is adminis- tered for a client experiencing gout and decreases the formation of tophi. 4. A thrombolytic medication is administered to dissolve a clot, and it may be ordered during the initial presentation for a client with a CVA, but not on discharge. TEST-TAKING HINT: In the stem of this question, there are two disease processes mentioned— atrial fibrillation and TIA. The reader must determine how one process affects the other before answering the question. In this question, the test taker must know that atrial fibrillation predisposes the client to the formation of thrombi ;and that, therefore, the nurse should anticipate the health-care provider ordering a medication to prevent clot formation, an anticoagulant.
2. The nurse is assessing a client experiencing motor loss as a result of a left-sided cerebrovascular accident (CVA). Which clinical manifestations would the nurse document? 1. Hemiparesis of the client's left arm and apraxia. 2. Paralysis of the right side of the body and ataxia. 3. Homonymous hemianopsia and diplopia. 4. Impulsive behavior and hostility toward family.
1. A left-sided CVA will result in right-sided motor deficits; hemiparesis is weakness of one half of the body, not just the upper extremity. Apraxia, the inability to perform a previously learned task, is a communication loss, not a motor loss. *2. The most common motor dysfunction of a CVA is paralysis of one side of the body, HEMIPLEGIA; in this case with a left-sided CVA, the paralysis would affect the right side. Ataxia is an impaired ability to coordinate movement.* 3. Homonymous hemianopsia (loss of half of the visual field of each eye) and diplopia (double vision) are visual field deficits that a client with a CVA may experience, but they are not motor losses. 4. Personality disorders occur in clients with a right-sided CVA and are cognitive deficits; hostility is an emotional deficit.
5. The nurse is planning care for a client experiencing agnosia secondary to a cerebrovascular accident. Which *collaborative* intervention will be included in the plan of care? 1. Observe the client swallowing for possible aspiration. 2. Position the client in a semi-Fowler's position when sleeping. 3. Place a suction setup at the client's bedside during meals. 4. Refer the client to an occupational therapist for evaluation.
1. Agnosia is the failure to recognize familiar objects; therefore, observing the client for possible aspiration is not appropriate. 2. A semi-Fowler's position is appropriate for sleeping, but agnosia is the failure to recognize familiar objects; therefore, this intervention is inappropriate. 3. Placing suction at the bedside will help if the client has dysphagia (difficulty swallowing), not agnosia, which is failure to recognize familiar objects. *4. A collaborative intervention is an intervention in which another health-care discipline—in this case, occupational therapy—is used in the care of the client.*
6. The nurse and an unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to *intervene*? 1. The assistant places a gait belt around the client's waist prior to ambulating. 2. The assistant places the client on the back with the client's head to the side. 3. The assistant places a hand under the client's right axilla to move up in bed. 4. The assistant praises the client for attempting to perform ADLs independently.
1. Placing a gait belt prior to ambulating is an appropriate action for safety and would not require the nurse to intervene. 2. Placing the client in a supine position with the head turned to the side is not a problem position, so the nurse does not need to intervene. *3. This action is inappropriate and would require intervention by the nurse because pulling on a flaccid shoulder joint could cause shoulder dislocation; the client should be pulled up by placing the arm underneath the back or using a lift sheet.* 4. The client should be encouraged and praised for attempting to perform any activities inde- pendently, such as combing hair or brushing teeth.
9. The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the plan of care? 1. Potential for injury. 2. Powerlessness. 3. Disturbed thought processes. 4. Sexual dysfunction.
1. Potential for injury is a physiological problem, not a psychosocial problem. *2. Expressive aphasia means that the client cannot communicate thoughts but understands what is being communicated; this leads to frustration, anger, depression, and the inability to verbalize needs, with, in turn, causes the client to have a lack of control and feel powerless.* 3. A disturbance in thought processes is a cognitive problem; with expressive aphasia the client's thought processes are intact. 4. Sexual dysfunction can have a psychosocial component or a physical component, but it is not related to expressive aphasia.
1. A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority? 1. Prepare to administer recombinant tissue plasminogen activator (rt-PA). 2. Discuss the precipitating factors that caused the symptoms. 3. Schedule for a STAT computed tomography (CT) scan of the head. 4. Notify the speech pathologist for an emergency consult.
1. The drug rt-PA may be administered, but a cerebrovascular accident (CVA) must be verified by diagnostic tests prior to administering it. rt-PA helps dissolve a blood clot, and it may be administered if an ischemic CVA is verified, rt-PA would not be given if the client were experiencing a hemorrhagic stroke. 2. Teaching is important to help prevent another CVA, but it is not the priority intervention on admission to the emergency department. Slurred speech indicates problems that may interfere with teaching. *3. A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. If a CVA is diagnosed, the CT scan can determine if it is a hemorrhagic or ischemic accident and guide treatment.* 4. The client may be referred for speech deficits and/or swallowing difficulty, but referrals are not priority in the emergency department.
11. The 85-year-old client diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first? 1. Administer a nonnarcotic analgesic. 2. Prepare for STAT magnetic resonance imaging (MRI). 3. Start an intravenous infusion with D5W at 100 mL/hr. 4. Complete a neurological assessment.
1. The nurse should not administer any medication to a client without first assessing the cause of the client's complaint or problem. 2. An MRI may be needed, but the nurse must determine the client's neurological status prior to diagnostic tests. 3. Starting an IV is appropriate, but it is not the action the nurse should implement when assessing pain, and 100 mL/hr might be too high a rate for an 85-year-old client. *4. The nurse must complete a neurological assessment to help determine the cause of the headache before taking any further action.* TEST-TAKING HINT: The test taker should always apply the nursing process when answering questions. If the test taker narrows down the choices to two possible answers, always select the assessment option as the first intervention.
The client has been diagnosed with a cerebrovascular accident (stroke). The client's wife is concerned about her husband's generalized weakness. Which home modification should the nurse suggest to the wife prior to discharge? 1. Obtain a rubber mat to place under the dinner plate. 2. Purchase a long-handled bath sponge for showering. 3. Purchase clothes with Velcro closure devices. 4. Obtain a raised toilet seat for the client's bathroom.
1. The rubber mat will stabilize the plate and prevent it from slipping away from the client learning to feed himself, but this does not address generalized weakness. 2. A long-handled bath sponge will assist the client when showering hard-to-reach areas, but it is not a home modification, nor will it help with generalized weakness. 3. Clothes with Velcro closures will make dress- ing easier, but they do not constitute a home modification and do not address generalized weakness. *4. Raising the toilet seat is modifying the home and addresses the client's weakness in being able to sit down and get up without straining muscles or requiring lifting assistance from the wife.*
10. Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? 1. A blood glucose level of 480 mg/dL. 2. A right-sided carotid bruit. 3. A blood pressure of 220/120 mm Hg. 4. The presence of bronchogenic carcinoma.
1. This glucose level is elevated and could predis- pose the client to ischemic neurological changes due to blood viscosity, but it is not a risk factor for a hemorrhagic stroke. 2. A carotid bruit predisposes the client to an embolic or ischemic stroke but not to a hemorrhagic stroke. *3. Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a ruptured blood vessel inside the cranium.* 4. Cancer is not a precursor to developing a hemorrhagic stroke. TEST-TAKING HINT: Both "1" and "2" are risk factors for an ischemic or embolic type of stroke. Knowing this, the test taker can rule out these answers as incorrect.