Chapter 67: Management of Patients With Cerebrovascular Disorders

Aspirin

If warfarin is contraindicated as a treatment for stroke, which medication is the best option? - Dipyridamole - Aspirin - Clopidogrel - Ticlodipine

use short, simple sentences.

When communicating with a client who has sensory (receptive) aphasia, the nurse should: - allow time for the client to respond. - speak loudly and articulate clearly. - give the client a writing pad. - use short, simple sentences.

dysarthria

A client diagnosed with a stroke is having difficulty forming words during communication. This would be appropriately documented as - dysphagia. - receptive aphasia. - dysarthria. - diplopia.

seasonal changes

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? - seasonal changes - reproductive hormone fluctuations - specific food chemicals - medications

B-C-E

A client is following up after a visit to the emergency department where testing indicated that the client had suffered a transient ischemic attack. What lifestyle changes would the nurse include in teaching to prevent further reoccurrence? Select all that apply. A. High-dose aspirin B. Blood pressure control C. Weight loss D. Physical activity limitations E. Smoking cessation

Restrict fluids before surgery.

A client on your unit is scheduled to have intracranial surgery in the morning. Which nursing intervention helps to avoid intraoperative complications, reduce cerebral edema, and prevent postoperative vomiting? - Restrict fluids before surgery. - Administer prescribed medications. - Administer preoperative sedation. - Administer an osmotic diuretic.

Perform a vision field assessment.

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? - Perform a vision field assessment. - Reposition the tray and plate. - Assist the client with feeding. - Know this is a normal finding for CVA.

Ask the client if he has trouble breathing

A nurse is caring for a client who has returned to his room after a carotid endarterectomy. Which action should the nurse take first? - Ask the client if he has trouble breathing. - Take the client's blood pressure. - Ask the client if he has a headache. - Place antiembolism stockings on the client.

A-D-E

A nurse is caring for a client with a cerebral aneurysm. Which nursing interventions would be most useful to the nurse to avoid bleeding in the brain? Select all that apply. A. Report changes in neurologic status as soon as a worsening trend is identified. B. Use a well-lighted room for assessments every 2 hours. C. Follow the healthcare provider's orders to increase fluid volume. D. Maintain the head of the bed at 30 degrees. E. Avoid any activities that cause a Valsalva maneuver.

Intracerebral hemorrhage

A nurse practitioner provides health teaching to a patient who has difficulty managing hypertension. This patient is at an increased risk of which type of stroke? - Intracerebral hemorrhage - Subarachnoid hemorrhage - Hemorrhage due to an aneurysm - Arteriovenous malformation

Tissue plasminogen activator (tPA)

A patient diagnosed with an ischemic stroke should be treated within the first 3 hours of symptom onset with which of the following? - Clopidogrel - Extended release dipyridamole - Tissue plasminogen activator (tPA) - Atorvastatin

Severe unilateral headache

The nurse is caring for a client recovering from a carotid endarterectomy. Which finding indicates to the nurse that the client is experiencing hyperperfusion syndrome? - Difficulty breathing - Decreased blood pressure - Severe unilateral headache - Change in vision in one eye

Hypertension

The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regimen, to maintain a healthy weight, and to adopt a reasonable exercise program. This advice is based on research data that shows the most important risk factor for stroke is: - Obesity - Dyslipidemia - Smoking - Hypertension

Speak slowly and clearly.

What nursing intervention is appropriate for a client with receptive aphasia? - Encourage the client to repeat sounds of the alphabet. - Explore the client's ability to write. - Speak slowly and clearly. - Frequently reorient the client to time, place, and situation.

Spatial-perceptual deficits

Which is indicative of a right hemisphere stroke? - Aphasia - Spatial-perceptual deficits - Slow, cautious behavior - Altered intellectual ability

Install a bed alarm to remind the client to ask for assistance and to alert staff that the client is getting out of bed.

A nurse is caring for an older client who has had a hemorrhagic stroke. The client has exhibited impulsive behavior and, despite reminders from the nurse, doesn't recognize his limitations. Which priority measure should the nurse implement to prevent injury? - Encourage the client to do as much as possible without assistance, and to use the call light only in emergencies. - Install a bed alarm to remind the client to ask for assistance and to alert staff that the client is getting out of bed. - Encourage the family to reprimand the client if he doesn't ask for help with transfers and mobility. - Ask a physician to order a vest and wrist restraints.

Hypertension

A nurse is providing education to a community group about ischemic strokes. One group member asks if there are ways to reduce the risk for stroke. Which of the following is a risk factor that can be modified? - Hypertension - Advanced age - Male gender - African heritage

Elevating the head of the bed to 30 degrees

After a stroke, a client is admitted to the facility. The client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g. Which nursing intervention is a priority for this client? - Checking stools for occult blood - Performing range-of-motion (ROM) exercises on the left side. - Keeping skin clean and dry - Elevating the head of the bed to 30 degrees

Encourage the patient to repeat sounds of the alphabet.

Which of the following statements reflects nursing management of the patient with expressive aphasia? - Encourage the patient to repeat sounds of the alphabet. - Speak clearly and in simple sentences; use gestures or pictures when able. - Speak slowly and clearly to assist the patient in forming the sounds. - Frequently reorient the patient to time, place, and situation.

Psychosis, disorientation, delirium, insomnia, and hallucinations

Which set of symptoms characterize Korsakoff syndrome? - Psychosis, disorientation, delirium, insomnia, and hallucinations - Severe dementia and myoclonus - Tremor, rigidity, and bradykinesia - Choreiform movement and dementia