Chapter 38: caring for clients with cerebrovascular prep u

A patient is admitted via ambulance to the emergency room of a stroke center at 1:30 p.m. with symptoms that the patient said began at 1:00 p.m. Within 1 hour, an ischemic stroke had been confirmed and the doctor ordered tPA. The nurse knows to give this drug no later than what time?

4:00 pm

A health care provider prescribes short-acting insulin for a patient, instructing the patient to take the insulin 20 to 30 minutes before a meal. The nurse explains to the patient that Humulin-R taken at 6:30 AM will reach peak effectiveness by:

8:30 AM.

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?

Absolute bed rest in a quiet, non stimulating environment

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?

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

Which clinical characteristic is associated with type 2 diabetes (previously referred to as non-insulin-dependent diabetes mellitus)?

Blood glucose can be controlled through diet and exercise

A client is admitted with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which laboratory finding should the nurse expect in this client?

Blood glucose level 1,100 mg/dl

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

A client diagnosed with aneurysm reports a severe headache to the nurse. What action is a priority for the nurse?

Call the health care provider immediately.

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

A patient presents to the emergency room with complaints of having an "exploding headache" for the last 2 hours. The patient is immediately seen by a triage nurse who suspects the patient is experiencing a stroke. Which of the following is a possible cause based on the characteristic symptom?

Cerebral aneurysm

A nurse is preparing a client with type 1 diabetes for discharge. The client can care for himself; however, he's had a problem with unstable blood glucose levels in the past. Based on the client's history, he should be referred to which health care worker?

Dietitian

A diabetes nurse educator is teaching a group of clients with type 1 diabetes about "sick day rules." What guideline applies to periods of illness in a diabetic client?

Do not eliminate insulin when nauseated and vomiting.

Which information should be included in the teaching plan for a client receiving glargine, which is "peakless" basal insulin?

Do not mix with other insulins.

A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to perform which action?

Form words that are understandable or comprehend spoken words

From which direction should a nurse approach a client who is blind in the right eye?

From the left side of the client

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

Frontal

Which is a nonmodifiable risk factor for ischemic stroke?

Gender

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

Heparin sodium

A client with diabetes mellitus is receiving an oral antidiabetic agent. The nurse observes for which condition when caring for this client?

Hypoglycemia

A nurse is preparing to administer insulin to a child who's just been diagnosed with type 1 diabetes. When the child's mother stops the nurse in the hall, she's crying and anxious to talk about her son's condition. The nurse's best response is:

I'm going to give your son some insulin. Then I'll be happy to talk with you."

NPH is an example of which type of insulin?

Intermediate-acting

'Which are contraindications for the administration of tissue plasminogen activator (t-PA)? Select all that apply.

Intracranial hemorrhage, major abdominal surgery within 10 days

A school nurse is teaching a group of high school students about risk factors for diabetes. What action has the greatest potential to reduce an individual's risk for developing diabetes?

Lose weight, if obese.

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?

Maintain and improve cerebral tissue perfusion.

Which clinical characteristic is associated with type 1 diabetes (previously referred to as insulin-dependent diabetes mellitus)?

Presence of islet cell antibodies

A nurse is teaching basic "survival skills" to a client newly diagnosed with type 1 diabetes. What topic should the nurse address?

Recognition of hypoglycemia and hyperglycemia

A patient has been newly diagnosed with type 2 diabetes, and the nurse is assisting with the development of a meal plan. What step should be taken into consideration prior to making the meal plan?

Reviewing the patient's diet history to identify eating habits and lifestyle and cultural eating patterns

The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient?

Semi-Fowler's

The nurse is participating in a health fair for stroke prevention. Which will the nurse say is a modifiable risk factor for ischemic stroke?

Smoking

A pregnant client has been diagnosed with gestational diabetes. The client is shocked by the diagnosis, stating that they are conscientious about their health, and asks the nurse what causes gestational diabetes. The nurse should explain that gestational diabetes is a result of what etiologic factor?

The effects of hormonal changes during pregnancy

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

A teenage client is brought to the emergency department with symptoms of hyperglycemia. Based on the fact that the pancreatic beta cells are being destroyed, the client would be diagnosed with what type of diabetes?

Type 1 diabetes

A nurse is providing education to a client who is newly diagnosed with diabetes mellitus. What are classic symptoms associated with diabetes?

increased thirst, hunger, and urination

A client with a history of type 1 diabetes is demonstrating fast, deep, labored breathing and has fruity odored breath. What could be the cause of the client's current serious condition?

ketoacidosis

A client admitted to the emergency department is being evaluated for the possibility of a stroke. Which assessment finding would lead the nurse to suspect that the client is experiencing a hemorrhagic stroke?

severe exploding headache

An agitated, confused client arrives in the emergency department. The client's history includes type 1 diabetes, hypertension, and angina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42 mg/dl, and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemia by ingesting:

10 to 15 g of a simple carbohydrate.

A nurse is caring for a client with type 1 diabetes who exhibits confusion, light-headedness, and aberrant behavior. The client is conscious. The nurse should first administer:

15 to 20 g of a fast-acting carbohydrate such as orange juice.

The pathophysiology of an ischemic stroke involves the ischemic cascade, which includes the following steps. Place the steps in the order in which they occur. All options must be used. 1. Change in pH 2. Blood flow decreases 3. A switch to anaerobic respiration 4. Membrane pumps fail 5. Cells cease to function 6. Lactic acid is generated

236145

A nurse is providing education on how to use a glucometer to a client newly diagnosed with diabetes mellitus. Which blood glucose values will represent the desired reading?

90 to 130 mg/dL before meals and <180 mg/dL 1 to 2 hours after meals

A patient had a carotid endarterectomy yesterday and when the nurse arrived in the room to perform an assessment, the patient states, "All of a sudden, I am having trouble moving my right side." What concern should the nurse have about this complaint?

A thrombus formation at the site of the endarterectomy

A client has received a diagnosis of type 2 diabetes. The diabetes nurse has made contact with the client and will implement a program of health education. What is the nurse's priorityaction?

Assess the client's readiness to learn.

The nurse is caring for a client who is known to be at risk for cardiogenic embolic strokes. Whatarrhythmia does this client most likely have?

Atrial fibrillation

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?

Depression

A client who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurse's care of this client?

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

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?

Thrombolytic therapy has a time window of only 3 hours.

Which intervention is essential when performing dressing changes on a client with a diabetic foot ulcer?

Using sterile technique during the dressing change

A nurse is reading a journal article about stroke and the underlying causes associated with this condition. The nurse demonstrates understanding of the information when identifying which subtype of stroke as being due to atrial fibrillation?

cardio embolic

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:

thickened commercial beverages and fortified cooked cereals.

A client with diabetes mellitus has a blood glucose level of 40 mg/dL. Which rapidly absorbed carbohydrate would be most effective?

1/2 cup fruit juice or regular soft drink

The nurse is administering lispro insulin. Based on the onset of action, how long before breakfast should the nurse administer the injection?

10 to 15 minutes

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 client recently had a stroke. Now the client has spasms in his/her hands, which is preventing a favorite hobby of knitting. The client is looking for a permanent solution to this problem. Which therapies would the nurse recommend?

Baclofen and stretching

A nurse expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other laboratory finding should the nurse anticipate?

Below-normal serum potassium level

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?

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

A nurse is providing health education to a teenage client newly diagnosed with type 1 diabetes mellitus, as well as the client's family. The nurse teaches the client and family nonpharmacologic measures that will decrease the body's need for insulin. What measure provides the greatest impact on glucose reduction?

Exercise

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?

Frustration around changes in function and communication

A client presents to the ED with a stiff neck, headache, and visual disturbances. The client is lethargic and has weakness on the left side. A CT scan reveals a ruptured aneurysm with a slow leak. The client's significant other is very concerned about the status and prognosis of the client. Based on the Hunt-Hess Scale, what grade will the physician most likely assign to the client that will assist in discussing the client's prognosis with the family?

Grade lll rational: Grade III classification criteria include lethargy or confusion and minor focal deficits such as hemiparesis (weakness on one side). The client's symptoms are consistent with grade III classification.

A student with diabetes reports feeling nervous and hungry. The school nurse assesses thestudent and finds the child has tachycardia and is diaphoretic with a blood glucose level of 50 mg/dL (2.8 mmol/L). What should the school nurse administer?

Half of a cup of juice, followed by cheese and crackers

A client is experiencing dysphagia following a stroke. Which measure may be taken by the nurse to ensure that the client's diet allows for easy swallowing?

Help the client sit upright when eating and feed slowly.

A client undergoes cerebral angiography for evaluation of a subarachnoid hemorrhage. Which findings indicate spasm or occlusion of a cerebral vessel by a clot?

Hemiplegia, seizures, and decreased level of consciousness

Which combination of adverse effects should a nurse monitor for when administering IV insulin to a client with diabetic ketoacidosis?

Hypokalemia and hypoglycemia

A client is evaluated for type 1 diabetes. Which client comment correlates best with this disorder?

I'm thirsty all the time. I just can't get enough to drink."

A patient who is diagnosed with type 1 diabetes would be expected to:

Need exogenous insulin.

Which clinical manifestation would be exhibited by a client following a hemorrhagic stroke of the right hemisphere?

Neglect of the left side

A nurse expects to find which signs and symptoms in a client experiencing hypoglycemia?

Nervousness, diaphoresis, and confusion

A client is suspected of having had a stroke. Which is the initial diagnostic test for a stroke?

Noncontrast computed tomography

The nurse is caring for a client with dysphagia. Which intervention would be contraindicated while caring for this client?

Placing food on the affected side of the mouth

The client has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the client's atmosphere more conducive to communication?

Provide a board of commonly used needs and phrases.

The nurse is administering an insulin drip to a patient in ketoacidosis. What insulin does the nurse know is the only one that can be used intravenously?

Regular

A client with diabetes mellitus has a prescription for 5 units of U-100 regular insulin and 25 units of U-100 isophane insulin suspension (NPH) to be taken before breakfast. At about 4:30 p.m., the client experiences headache, sweating, tremor, pallor, and nervousness. What is the most probable cause of these signs and symptoms?

Serum glucose level of 52 mg/dl

A patient is exhibiting classic signs of a hemorrhagic stroke. What complaint from the patient would be an indicator of this type of stroke?

Severe headache

A patient is exhibiting classic signs of a hemorrhagic stroke. What complaint from the patient would be an indicator of this type of stroke? '

Severe headache

Which is a modifiable risk factor for transient ischemic attacks and ischemic strokes?

Smoking

The nurse is preparing health education for a client who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in this education?

Take antihypertensive medication as prescribed.

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

An emergency department nurse is awaiting the arrival of a client with signs of an ischemic stroke that began 1 hour ago, as reported by emergency medical personnel. The treatment window for thrombolytic therapy is which of the following?

Three hours

A client is receiving medical management for a history of transient ischemic attacks (TIAs). The client's health care provider has prescribed an oral anticoagulant to prevent a more serious cerebrovascular accident. The nurse is to monitor the client's:

prothrombin level.

The nurse is reviewing the medication administration record of a client who possesses numerous risk factors for stroke. Which of the client's medications carries the greatest potential for reducing her risk of stroke?

Aspirin 81 mg PO o.d.

A client with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the client's cardiac and neurologic status, the nurse monitors the client for signs of what complication?

Bleeding

A nurse is educating a group of nursing students about signs and symptoms of a hemorrhagic stroke. Which is true of hemorrhagic stroke?

Can occur in the subarachnoid space.

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

The nurse is caring for a client recovering from a stroke. Which action will the nurse take to prevent adduction of the client's affected shoulder? Select all that apply.

Place a pillow in the axilla area, Position the wrist higher than the elbow.

A client is diagnosed with a right-sided stroke. The client is now experiencing hemianopsia. How might the nurse help the client manage the potential sensory and perceptional difficulties?

Place the client's extremities where the client can see them.

A client with a left hemispheric stroke is having difficulty with their normal speech patterns. The nurse is not sure whether the client has expressive aphasia or apraxia. Which statement would most likely be reflective of apraxia?

The client starts by saying "good morning" but finishes with saying "good day" to the nurse.

The client with a cerebral aneurysm asks the nurse, "What's the big fuss over a headache?" Which is the best response from the nurse regarding to a cerebral aneurysm?

Your physician wants to evaluate the location and condition of the aneurysm."

A nurse is assessing a client who has diabetes for the presence of peripheral neuropathy. The nurse should question the client about what sign or symptom that would suggest the possible development of peripheral neuropathy?

The presence of a tingling sensation