Chapter 38: Caring for Clients with Cerebrovascular Disorders

A nurse is assisting with a community screening for people at high risk for stroke. To which of the following clients would the nurse pay most attention? A 60-year-old Black man A 28-year-old pregnant Black woman A 62-year-old White woman A 40-year-old White woman

A 60-year-old Black man p.651

A client with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this client? Early initiation of physical therapy Absolute bed rest in a quiet, non stimulating environment Passive range-of-motion exercises to prevent contractures Supine positioning

Absolute bed rest in a quiet, non stimulating environment p. 656

A clinic nurse is caring for a client diagnosed with migraine headaches. During the client teaching session, the client questions the nurse regarding alcohol consumption. What would the nurse be correct in telling the client about the effects of alcohol? Alcohol causes hormone fluctuations. Alcohol diminishes endorphins in the brain. Alcohol has an excitatory effect on the CNS. Alcohol causes vasodilation of the blood vessels.

Alcohol causes vasodilation of the blood vessels.

The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration? Alteration in level of consciousness (LOC) Shortness of breath Generalized pain Tonic-clonic seizures

Alteration in level of consciousness (LOC) p.651

The nurse is taking care of a client with a headache. In addition to administering medications, the nurse takes which measure to assist the client in reducing the pain associated with the headache? Use pressure-relieving pads or a similar type of mattress. Maintain hydration by drinking eight glasses of fluid a day. Apply warm or cool cloths to the forehead or back of the neck. Perform the Heimlich maneuver.

Apply warm or cool cloths to the forehead or back of the neck.

The nurse is caring for a client who is known to be at risk for cardiogenic embolic strokes. What arrhythmia does this client most likely have? Ventricular tachycardia Supraventricular tachycardia Atrial fibrillation Bundle branch block

Atrial fibrillation p. 648

A patient who has had a previous stroke and is taking warfarin tells the nurse that he started taking garlic to help reduce his blood pressure. The nurse knows that garlic when taken together with warfarin will produce which type of interaction? No drug to drug interactions, may be taken together Can greatly increase the international normalization ratio (INR), increasing the risk of bleeding May increase cerebral blood flow, causing migraine headaches Can cause platelet aggregation, increasing the risk of blood clotting

Can greatly increase the international normalization ratio (INR), increasing the risk of bleeding p. 648.

A patient who just suffered a hemorrhagic stroke is brought to the emergency department by ambulance. What should be the nurse's primary assessment focus? Cardiac and respiratory status Fluid and electrolyte balance Urinary output Seizure activity

Cardiac and respiratory status pp. 649-650.

A community health nurse is conducting a workshop for unlicensed care providers who work in a chain of long-term care facilities. The nurse is teaching the participants about the signs and symptoms of stroke. What signs and symptoms should the nurse identify? Select all that apply. Sudden numbness Sudden ear pain Confusion Epistaxis (nosebleed) Visual disturbances

Confusion Sudden numbness Visual disturbances

The nurse is discharging home a client who had a stroke. The client has a flaccid right arm and leg and is experiencing urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common client response to a change in body image? Confusion Depression Disassociation Uncertainty

Depression

A nursing student is writing a care plan for a newly admitted client who has been diagnosed with a stroke. What major nursing diagnosis should most likely be included in the client's plan of care? Disturbed sensory perception Post-trauma syndrome Adult failure to thrive Hyperthermia

Disturbed sensory perception

When caring for a client who has had a stroke, a priority is reduction of ICP. What client position is most consistent with this goal? Head turned slightly to the right side Extension of the neck Position changes every 15 minutes while awake Elevation of the head of the bed

Elevation of the head of the bed pg.656

A client is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this client is aware that an absolute contraindication for thrombolytic therapy is what? Evidence of stroke evolution Previous thrombolytic therapy within the past 12 months Evidence of hemorrhagic stroke Blood pressure of ≥ 180/110 mm Hg

Evidence of hemorrhagic stroke Thrombolytic therapy would exacerbate a hemorrhagic stroke with potentially fatal consequences. Stroke evolution, high BP, or previous thrombolytic therapy does not contraindicate its safe and effective use.

A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to perform which action? Comprehend spoken words Form words that are understandable or comprehend spoken words Form words that are understandable Speak at all

Form words that are understandable or comprehend spoken words p. 651

From which direction should a nurse approach a client who is blind in the right eye? From directly behind the client From directly in front of the client From the right side of the client From the left side of the client

From the left side of the client pp. 654-655

A stroke victim is experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe? Temporal Frontal Occipital Parietal

Frontal

When preparing to discharge a client home, the nurse has met with the family and warned them that the client may exhibit unexpected emotional responses. The nurse should teach the family that these responses are typically a result of what cause? Unmet physiologic needs Frustration around changes in function and communication Temporary changes in metabolism Changes in brain activity during sleep and wakefulness

Frustration around changes in function and communication

A client undergoes cerebral angiography for evaluation of a subarachnoid hemorrhage. Which findings indicate spasm or occlusion of a cerebral vessel by a clot? Difficulty breathing or swallowing Nausea, vomiting, and profuse sweating Tachycardia, tachypnea, and hypotension Hemiplegia, seizures, and decreased level of consciousness

Hemiplegia, seizures, and decreased level of consciousness pg. 656

A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? Heparin sodium Dexamethasone Methyldopa Phenytoin

Heparin sodium p. 653

The nurse is educating a group of people newly diagnosed with migraine headaches. What information should the nurse include in the educational session? Select all that apply. Maintain a headache diary. Sleep no more than 5 hours at a time. Exercise in a dark room. Keep a food diary. Use St. John's Wort.

Keep a food diary. Maintain a headache diary. pg 646

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention? Maintaining the client in a quiet environment Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess Positioning the client to prevent airway obstruction Keeping the client in one position to decrease bleeding

Keeping the client in one position to decrease bleeding

What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke? Left visual field deficit Altered intellectual ability Aphasia Slow, cautious behavior

Left visual field deficit p. 651.

A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem? Heparin Lioresal (Baclofen) Pregabalin (Lyrica) Diphenhydramine (Benadryl)

Lioresal (Baclofen)

A nurse is caring for a client diagnosed with a hemorrhagic stroke. When creating this client's plan of care, what goal should be prioritized? Relieve anxiety and pain. Prevent complications of immobility. Maintain and improve cerebral tissue perfusion. Relieve sensory deprivation.

Maintain and improve cerebral tissue perfusion. Each of the listed goals is appropriate in the care of a client recovering from a stroke. However, promoting cerebral perfusion is a priority physiologic need, on which the client's survival depends.

Which clinical manifestation would be exhibited by a client following a hemorrhagic stroke of the right hemisphere? Inability to move the right arm Neglect of the right side Expressive aphasia Neglect of the left side

Neglect of the left side p. 651

Which is the initial diagnostic test for a stroke? Carotid Doppler Transcranial Doppler studies Noncontrast computed tomography Electrocardiography

Noncontrast computed tomography p.652

The nurse is caring for a client with dysphagia. Which intervention would be contraindicated while caring for this client? Testing the gag reflex before offering food or fluids Placing food on the affected side of the mouth Allowing ample time to eat Assisting the client with meals

Placing food on the affected side of the mouth

The nurse practitioner is able to correlate a patient's neurologic deficits with the location in the brain affected by ischemia or hemorrhage. For a patient with a left hemispheric stroke, the nurse would expect to see: Left visual field deficit. Spatial-perceptual deficits. Right-sided paralysis. Impulsive behavior.

Right-sided paralysis.

The nurse practitioner is able to correlate a patient's neurologic deficits with the location in the brain affected by ischemia or hemorrhage. For a patient with a left hemispheric stroke, the nurse would expect to see: Left visual field deficit. Spatial-perceptual deficits. Impulsive behavior. Right-sided paralysis.

Right-sided paralysis. p.651

The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient? Prone Supine High-Fowler's Semi-Fowler's

Semi-Fowler's

Which is a modifiable risk factor for transient ischemic attacks and ischemic strokes? Thyroid disease Advanced age Smoking Social drinking

Smoking

A rapid response and stroke alert/code has been called for a client with deep vein thrombosis (DVT) of the left leg being treated with intravenous heparin. The client's international normalized ratio (INR) is 2.1 and vital signs are: Temperature 100.1°F (37.8°C), heart rate 102, blood pressure 190/100, respirations 14, and saturation 89% on room air. What are priority interventions for a client who is currently on anticoagulant therapy and having an ischemic stroke? Supplemental oxygen and monitoring blood glucose levels Antipyretics in order to keep the client in a state of hypothermia Antihypertensive medications and vital signs every two hours Immediate intubation and urinary catheter placement

Supplemental oxygen and monitoring blood glucose levels

A client who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurse's care of this client? Attention to the affected side should be minimized in order to decrease anxiety. The client should be approached on the side where visual perception is intact. The client should avoid turning in the direction of the defective visual field to minimize shoulder subluxation. The client should be approached on the opposite side of where the visual perception is intact to promote recovery.

The client should be approached on the side where visual perception is intact.

A client who has experienced an ischemic stroke has been admitted to the medical unit. The client's family is adamant that the client remain on bed rest to hasten recovery and to conserve energy. What principle of care should inform the nurse's response to the family? Lack of mobility will greatly increase the client's risk of stroke recurrence. The client should remain on bed rest until the client expresses a desire to mobilize. The client should mobilize as soon as physically able. To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks.

The client should mobilize as soon as physically able. p. 654.

A nurse is teaching a community class that those experiencing symptoms of ischemic stroke need to enter the medical system early. The primary reason for this is which of the following? A ruptured arteriovenous malformation will cause deficits until it is stopped. Thrombolytic therapy has a time window of only 3 hours. Intracranial pressure is increased by a space-occupying bleed. A ruptured intracranial aneurysm must quickly be repaired.

Thrombolytic therapy has a time window of only 3 hours. p. 652.

A client diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for which purpose? To remove atherosclerotic plaques blocking cerebral flow To determine the cause of the TIA To decrease cerebral edema To prevent seizure activity that is common following a TIA

To remove atherosclerotic plaques blocking cerebral flow The main surgical procedure for select patients with TIAs is carotid endarterectomy, the removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in patients with occlusive disease of the extra cranial arteries. An endarterectomy does not decrease cerebral edema, prevent seizure activity, or determine the cause of a TIA.

The nurse is performing stroke risk screenings at a hospital open house. Identification of high-risk individuals is the goal of the screenings. The nurse has identified four patients who might be at risk for a stroke. Which patient is likely at highest risk for a stroke? Black man, age 50 with history of smoking White man, age 60 with history of uncontrolled hypertension White woman, age 60 with history of excessive alcohol intake Black man, age 60, with history of diabetes

White man, age 60 with history of uncontrolled hypertension p. 651.

A client has been having cluster headaches intermittently over the last year. In an effort to determine the trigger for the cluster headaches, the client has maintained a journal of all oral consumption. What on the list would the nurse suspect could be triggering headaches? alcoholic beverages dairy products commercially-prepared food spicy foods

alcoholic beverages p. 644

A client reports light-headedness, speech disturbance, and left-sided weakness that have lasted for several hours. In the examination, an abnormal sound is auscultated in an artery leading to the brain. What is the term for the auscultated discovery? bruit TIA atherosclerotic plaque diplopia

bruit pg. 647

A client has a 12-year history of migraine headaches and is frustrated over how these headaches impact lifestyle. The nurse discusses the potential triggers of the client's migraines. Which is not a potential trigger to migraines? specific food chemicals reproductive hormone fluctuations medications seasonal changes

seasonal changes Researchers believe the contributing cofactors for the cause of migraines are from changes in serotonin receptors that promote dilation of cerebral blood vessels and pain intensification from neurochemicals released from the trigeminal nerve. It has been suggested that fluctuations in reproductive hormones, chemicals in certain foods, and medications can trigger migraines

A client reports frequent headaches and is seeing the physician to determine their cause. In client education, which type of headache does the nurse indicate is most common? tension cluster secondary migraine

tension

The nurse is providing diet-related advice to a client who experienced a cerebrovascular accident (CVA). The client wants to minimize his volume of food and yet meet all nutritional requirements. To control the volume of food intake, the nurse should suggest that the client consume: hot or tepid foods. dry or crisp foods and chewy meats. thickened commercial beverages and fortified cooked cereals. a high-fat diet.

thickened commercial beverages and fortified cooked cereals. p. 653

The nurse is providing diet-related advice to a client who experienced a cerebrovascular accident (CVA). The client wants to minimize his volume of food and yet meet all nutritional requirements. To control the volume of food intake, the nurse should suggest that the client consume: a high-fat diet. dry or crisp foods and chewy meats. thickened commercial beverages and fortified cooked cereals. hot or tepid foods.

thickened commercial beverages and fortified cooked cereals. p. 653.

A client has a 12-year history of migraine headaches and is frustrated over how these headaches impact lifestyle. What would the nurse indicate to the client is the origin of migraines? vascular muscular light endocrine

vascular