Chapter 38: Caring for Clients With Cerebrovascular Disorders
15. A client with a cerebrovascular accident (CVA) is having difficulty with eating food on the plate. Which is the best priority nursing action to be taken? A. Perform a vision field assessment. B. Reposition the tray and plate. C. Assist the client with feeding. D. Know this is a normal finding for CVA.
ANS: A Rationale: The nurse should perform a vision field assessment to evaluate the client for hemianopia. This finding could indicate damage to the visual area of the brain as a result of evolving CVA. Repositioning the tray and assisting with feeding would not be the best nursing action until new finding has been evaluated. Hemianopia can be associated with a CVA but, when presenting as a new finding, should be evaluated and reported immediately.
17. Which nursing assessment finding is most indicative of a hemorrhagic stroke? A. Client history of atrial fibrillation B. Sudden onset of breathing alterations C. Symptoms evolving over 24 to 48 hours D. Client history of hyperlipidemia
ANS: B Rationale: Hemorrhagic strokes are less common than ischemic strokes and usually present with sudden onset and have the most impact on breathing, blood pressure, and heart rate. Client history of atrial fibrillation and hyperlipidemia are most significant with ischemic strokes caused by embolus or plaque. Ischemic strokes tend to evolve over 24 to 48 hours until symptoms complete.
10. The nurse is providing teaching to a client who reports tension headaches. Which instruction would be beneficial to prevent onset of symptoms? A. Apply cool or warm cloth to head or eyes. B. Eliminate use of bright lights when working. C. Avoid certain foods. D. Perform stretching exercises and frequent position changes.
ANS: D Rationale: Tension headaches are often associated with prolonged tensed muscles. Application of cool or warm cloths and avoidance of bright lights may help to reduce the headache after occurrence. Avoiding certain foods may prevent migraine headaches but is not likely to prevent tension headaches.
12. The nurse is assessing a client for a possible transient ischemic attack (TIA). Which of the following assessment findings suggests that the client is experiencing a TIA? A. Impaired muscle coordination B. Respiratory distress C. Severe headache D. Nausea and vomiting
ANS: A Rationale: A client with a TIA may experience impaired muscle coordination or paralysis on one side. Respiratory distress and severe headache are not associated with TIA. Nausea and vomiting is not a usual symptom of TIA.
3. A client has just been diagnosed with a cerebral aneurysm. In planning discharge teaching for this client, what instructions should be delivered by the nurse to the client? A. Avoid heavy lifting. B. Avoid fiber in the diet. C. Take an antacid frequently. D. Take an herbal form of feverfew.
ANS: A Rationale: A client with an aneurysm should be advised to avoid heavy lifting, extreme emotional situations, or straining of stools because these activities increase intracranial pressure and thereby headaches and potential rupture of aneurysm. Avoidance of fiber may lead to constipation and straining with stools and would not be recommended. There would not be a recommendation for antacids or feverfew in the discharge teaching.
1. The nurse is caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke does the nurse know this client has? A. Ischemic B. Hemorrhagic C. Right-sided D. Left-sided
ANS: A Rationale: Ischemic strokes occur when a thrombus or embolus obstructs an artery carrying blood to the brain; about 80% of strokes are the ischemic variety. The other options are incorrect. PTS: 1 REF: p. 649, Cerebrovascular Accident (Stroke) NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter: 38 KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice
21. A client is prescribed sumatriptan for the treatment of migraine headache. Which client statement would indicate a need for additional teaching from the nurse? A. "I use this to prevent migraines." B. "I take this when I get a headache." C. "It constricts the blood vessels in my head." D. "It alleviates my sensitivity to light and sound."
ANS: A Rationale: Sumatriptan is a serotonin receptor agonist that stimulates serotonin receptors in the brain and causes vasoconstriction of the cerebral arteries and reduce/eliminate headaches and other symptoms associated with migraines. Sumatriptan is used during an attack and is not indicated for preventative migraine therapy.
5. A client diagnosed with migraine headaches asks the nurse what to do to help control the headaches and minimize the number of attacks. What instructions should the nurse give this client? A. Identify and avoid factors that precipitate or intensify an attack. B. Keep a record of activities following an attack. C. When an attack occurs, stay in a brightly lit area. D. Write down any adverse drug effects.
ANS: A Rationale: The nurse includes the following instructions: Follow the indications and dosage regimen for medication and notify the physician of any adverse drug effects. Identify and avoid factors that precipitate or intensify an attack. Keep a food diary, which may help identify foods that trigger attacks. Keep a record of the attacks, including activities before the attack and environmental or emotional circumstances that appear to bring on the attack. Lie down in a darkened room and avoid noise and movement when an attack occurs whenever possible. PTS: 1 REF: p. 646, Headache NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter: 38 KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice
13. A client with a history of atrial fibrillation has experienced a TIA. What does the nurse expect will be the priority preventative medical treatment(s) to reduce the risk of a cerebrovascular accident (CVA)? Select all that apply. A. Cholesterol-lowering drugs B. Anticoagulant therapy C. Monthly prothrombin levels D. Carotid endarterectomy E. Percutaneous transluminal angioplasty
ANS: A, B Rationale: To manage atherosclerosis and the consequences of cardiac arrhythmias, especially atrial fibrillation, cholesterol-lowering drugs and prophylactic anticoagulant or antiplatelet therapy are prescribed. Prothrombin and international normalized ratio (INR) levels may be prescribed to monitor therapeutic effects of anticoagulant therapy. Carotid endarterectomy would be anticipated only when the carotids have narrowing from plaque. Similarly, a percutaneous transluminal angioplasty (also called a balloon angioplasty) accompanied by placement of a stent is performed to dilate the carotid artery and increase blood flow to the brain.
7. A family member comes to the clinic to talk to the nurse about a client who has had a stroke on the right side of the brain. The family member is concerned because of the deficits the client is exhibiting. The nurse knows that when a client experiences a stroke on the right side of the brain, common deficits include what? Select all that apply. A. Left-sided hemiplegia B. Tendency to distractibility C. Impairment of long-term memory D. Hyperaware of deficits E. Neglect of objects and people on the left side
ANS: A, B, E Rationale: Left-sided hemiplegia (stroke on right side of brain) may have the following neurologic deficits: spatial-perceptual defects; disregard for the deficits of the affected side require special safety considerations; tendency to distractibility; impulsive behavior, unaware of deficits; poor judgment; defects in left visual fields; misjudge distances; difficulty distinguishing upside-down and right-side up; impairment of short- term memory; and neglect left side of body, objects and people on left side.
25. The nurse is completing an assessment on a client with a history of migraines. The nurse would identify factor(s) as a possible trigger for a migraine headache? Select all that apply. A. Red wine B. Nausea C. Menstruation D. Exposure to flashing light E. Change in environmental temperature F. Prolonged positioning
ANS: A, C, D Rationale: Research on the cause of migraines is ongoing; however, changes in reproductive hormones (menstruation), exposure to flashing light, and particular food/beverages and alcohol can be a trigger for some clients. Nausea is a symptom of a migraine. Exposure to changes in environmental temperature does not trigger a migraine headache. Prolonged positioning can cause muscle fatigue and strain that trigger tension headaches.
8. A family member brings a 76-year-old client to the clinic, stating that the client has had two transient ischemic attacks (TIAs) in the past week. The health care provider orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option(s) does the nurse expect the health care provider to offer this client to increase blood flow to the brain? Select all that apply. A. Balloon angioplasty of the carotid artery followed by stent placement B. Removal of the carotid artery C. Percutaneous transluminal coronary artery angioplasty D. Carotid endarterectomy E. Administration of tissue plasminogen activator
ANS: A, D Rationale: If narrowing of the carotid artery by atherosclerotic plaques is the cause of the TIAs, a carotid endarterectomy (surgical removal of atherosclerotic plaque) could be performed. A balloon angioplasty of the carotid artery, a procedure similar to a percutaneous transluminal coronary artery angioplasty, may be performed alternatively to dilate the carotid artery and increase blood flow to the brain, followed by stent placement. The other options are not options to increase blood flow through the carotid artery to the brain.
9. A female client who complains of recurring headaches, accompanied by increased irritability, photophobia, and fatigue is asked to track the headache symptoms and occurrence on a calendar log. Which is the best nursing rationale for this action? A. Cluster headaches can cause severe debilitating pain. B. Migraines often coincide with menstrual cycle. C. Tension headaches are easier to treat. D. Headaches are the most common type of reported pain.
ANS: B Rationale: Changes in reproductive hormones as found during the menstrual cycle can be a trigger for migraine headaches and may assist in the management of the symptoms. Cluster headaches can cause severe pain, but this is not the reason for tracking. Tension headaches can be managed, but this is not associated with a monthly calendar. Headaches are common, but that is not the reason for tracking.
22. An older adult client, who has fallen several times at home, is admitted for possible transient ischemic attack (TIA). Which assessment finding is most significant in determining care for this client? A. Becoming confused during the night B. Drooling from side of mouth C. Bruit heard over carotids D. Irregular heart rhythm
ANS: B Rationale: Facial droop and drooling from the side of the mouth can indicate progression of symptoms or evolving CVA. It is not unusual for older adult clients to become confused when placed in a new environment and would indicate a need for further assessment. Bruits over the carotids may indicate altered blood flow to the brain but may not be a new finding for this client. Irregular heart rate can be indicative of atrial fibrillation or other cardiac disorders.
23. A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which finding? A. Transient ischemic attack (TIA). B. Left-sided cerebrovascular accident (CVA). C. Right-sided cerebrovascular accident (CVA). D. Completed Stroke.
ANS: B Rationale: When the infarct is on the left side of the brain, the symptoms are likely to be on the right, and the speech is more likely to be involved. If the MRI reveals an infarct, TIA is no longer the diagnosis. There is not enough information to determine if the stroke is still evolving or is complete.
16. A client has been found unresponsive at home for an undetermined period of time. A cerebrovascular accident (CVA) is suspected, and the family is demanding a clot buster be used to restore functioning. The nurse knows that successful use of tissue plasminogen activator (TPA) in a client with CVA requires which factor(s) to be true? Select all that apply. A. Symptoms no longer evolving B. Presence of an ischemic stroke C. Used concurrently with heparin therapy D. Administered intramuscularly for faster response E. Administered within 3 hours of onset of symptoms F. Administered for hemorrhagic strokes
ANS: B, E Rationale: TPA is a thrombolytic agent that can limit neurologic deficits if given IV within 3 hours of onset of an ischemic CVA. Waiting for symptoms to stabilize (no longer evolving) may take days and would not be appropriate for the use of TPA. TPA is not used in conjunction with other anticoagulants and would never be used to treat a hemorrhagic stroke (promotes more bleeding).
6. While making initial rounds after coming on shift, the nurse finds a client thrashing about in bed complaining of a severe headache. The client tells the nurse the pain is behind the right eye, which is red and tearing. What type of headache would the nurse suspect this client of having? A. Migraine B. Tension C. Cluster D. Sinus
ANS: C Rationale: A person with a cluster headache has pain on one side of the head, usually behind the eye, accompanied by nasal congestion, rhinorrhea (watery discharge from the nose), and tearing and redness of the eye. The pain is so severe that the person is not likely to lie still; instead, the person may pace or thrash about. The symptoms in the scenario do not describe the other types of headaches listed. PTS: 1 REF: p. 643, Headache NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter: 38 KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice
14. A client is brought to the emergency department with symptoms of a cerebrovascular accident (CVA). The nurse would anticipate which diagnostic evaluation to be completed prior to initiation of treatment? A. Prothrombin level B. Chest x-ray C. Brain CT scan or MRI D. Lumbar puncture
ANS: C Rationale: CT scan or MRI differentiates CVA from other disorders and can differentiate between ischemic or hemorrhagic strokes. PT level would be done if the client is receiving anticoagulant therapy. Chest x-ray may be performed if respiratory concerns are indicated. Lumbar puncture would be done if subarachnoid bleeding is suspected.
18. A diagnostic test has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include thickened liquids. Which of the following is the priority nursing diagnosis for this client? A. Decreased Fluid Volume Risk B. Aspiration Risk C. Impaired Swallowing D. Malnutrition Risk
ANS: C Rationale: Impaired Swallowing was evident on the video fluoroscopy. Aspiration, Malnutrition, and Decreased Fluid Volume Risk can occur but are not the primary diagnosis at this point in time.
4. A client has tension headaches. The nurse recommends massage as a treatment for tension headaches. How does massage help clients with tension headaches? A. Reduces hypotension B. Increases appetite C. Relaxes muscles D. Relieves migraines
ANS: C Rationale: Massaging relaxes tense muscles, causes local dilation of blood vessels, and relieves headache. However, this approach is not likely to help a client with migraine or cluster headaches. Massage is not offered to clients with tension headaches to increase their appetite or reduce hypotension. PTS: 1 REF: p. 646, Headache NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter: 38 KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Choice
19. A client is admitted for evaluation of cerebral aneurysm. Which assessment finding is of greatest importance in prioritizing nursing care to this client? A. Complaint of headache off and on for past month. B. No bowel movement since yesterday C. Nausea D. Frequent voiding
ANS: C Rationale: Nausea needs to be controlled to prevent vomiting, which can greatly increase the intracranial pressure and subsequently rupture the aneurysm. Complaint of headache for the past month is significant to the evaluation at hand but should be addressed after the nausea has been controlled. Having no bowel movement since yesterday is not significant; although, every effort should be made to prevent constipation. Frequent voiding is expected especially with the use of osmotic diuretics.
24. A client has experienced a transient ischemic attack (TIA) and presents with carotid bruits. Which is the priority action to be taken by the nurse, following a bilateral carotid endarterectomy? A. Encourage deep breathing and coughing. B. Observe for facial swelling. C. Anticipate need for endotracheal intubation. D. Resume antilipemic drugs.
ANS: C Rationale: Surgical approach to the neck area can result in swelling and blockage of the airway. This is especially significant with bilateral carotid endarterectomy. The nurse must be observant and prepared for immediate intubation if the airway becomes obstructed. Encouraging deep breathing and coughing is not significant because general anesthesia is not routine. Resuming drugs for hyperlipidemia is not a priority in the acute postoperative period.
20. A client is brought into the emergency department with a diagnosis of ruptured cerebral aneurysm. Which assessment data provides the most important information in preparing for the nursing care of this client? A. Blood pressure 180/98 mm Hg B. Alert and oriented times three C. Grade V on the Hunt-Hess Scale D. Complaint of severe splitting headache
ANS: C Rationale: The Hunt-Hess Scale is used for grading a client with a cerebral aneurysm and provides the most accurate assessment as listed. An elevated blood pressure is anticipated with a cerebral aneurysm. Being alert and oriented provides little assessment value without additional neurologic data. Complaint of severe headache is subjective and not as significant as results from using the Hunt-Hess Scale.
2. A client presents to the walk-in clinic complaining of a migraine. The client is prescribed an antileptic. What should the nurse suggest to the client? A. Avoid crowds. B. Take drugs only after meals at night. C. Avoid caffeine and alcohol. D. Use caution while driving or performing hazardous activities.
ANS: D Rationale: A client who is prescribed an antileptic needs to exercise caution while driving and avoid performing hazardous activities. A client taking non-steroidal anti- inflammatory drugs should be advised against taking caffeine and alcohol. The client need not take the drug only at night after meals or be instructed to avoid crowds. PTS: 1 REF: p. 645, Headache NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter: 38 KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice
11. A client who has experienced an initial transient ischemic attack (TIA) states: "I'm glad it wasn't anything serious." Which is the best nursing response to this statement? A. "I sense that you are happy it was not a stroke". B. "People who experience a TIA will develop a stroke". C. "TIA symptoms are short-lived and resolve within 24 hours". D. "TIA is a warning sign. Let's talk about lowering your risks."
ANS: D Rationale: TIA is a warning sign and can be used to empower clients to make life changes to lower the risks. Sensing the client is happy is a psychotherapeutic response but does not lead to teaching and learning for health promotion. TIAs can lead to a stroke for approximately one third of the clients but is not a definitive result and presents as a frightening statement without empowering change. TIA symptoms are short-lived, but this is a factual statement that does not provide additional information to the client.
