Med Surg II Study for Exam ***

A patient has been undergoing rehabilitation for the past 3 weeks following a hemorrhagic stroke. The nurse has observed that the patient is motivated to perform his activities of daily living independently, but rarely attempts tasks with his affected arm. How should the nurse address this observation with the patient?

"Even though it requires a huge effort, using your affected arm will help you build its strength."

Disturbed by the high incidence and poor outcomes of stroke in the community, a public health nurse is planning a health promotion campaign that is specifically focused on stroke. Which of the following proposed outcomes would most directly address an identified public awareness need?

"Participants will state the most common signs and symptoms of stroke."

A client recently experienced a stroke with accompanying left-sided paralysis. His family voices concerns about how to best interact with him. They report the client doesn't seem aware of their presence when they approach him on his left side. What advice should the nurse give the family?

"The client is unaware of his left side. You should approach him on the right side."

Which interventions would be recommended for a client with dysphagia? Select all that apply.

-Assist the client with meals. -Test the gag reflex before offering food or fluids. -Allow ample time to eat.

The nurse is assessing a 78-year-old female client admitted with a stroke of recent onset, within 2 hours of admission. Vital signs: blood pressure, 150/90 mm Hg; pulse, 112 beats/min; respirations, 20 breaths/min; temperature, 100.4°F (38°C); pulse oximetry, 96% on room air. An audible murmur is heard upon auscultation. The client is awake but somewhat lethargic and cannot respond to questions. The client is exhibiting neurologic deficits and impaired mobility of the left side of the body. The client is being evaluated for tissue plasminogen activator (t-PA) therapy.

-CT confirmation of ischemic stroke -blood pressure reading -international normalized INR result of 2.0

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 nurse is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care? (select all that apply)

-have suction equipment available for use -feed the client thickened liquids -place food on the unaffected side of the client's mouth -teach the client to swallow with the neck flexed

A nurse is caring for a client who has experienced a right-hemispheric stroke. The nurse should expect the client to have difficulty with which of the following? (select all that apply)

-impulse control -moving the left side -depth perception -situational awareness

A nurse is caring for a client who has global aphasia (both receptive and expressive). Which of the following should the nurse include in the client's plan of care? (select all that apply)

-speak to the client at a slower rate -assist the client to use cards with pictures -give instructions one step at a time

An emergency department nurse understands that a 110-lb (50-kg) recent stroke victim will receive at least the minimum dose of recombinant tissue plasminogen activator (t-PA). What minimum dose will the client receive?

45 mg

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 p.m.

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 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 nurse who provides care at a community clinic is in contact with a diverse group of patients. Which of the following individuals most clearly displays risk factors for stroke?

An obese woman with a history of atrial fibrillation and type 2 diabetes

A patient has been admitted to a unit at a primary stroke center after experiencing an ischemic stroke. The nurse on the unit is aware of the vital importance of rehabilitative efforts and knows that an active rehabilitation program should begin at what point?

As soon as the patient regains consciousness

A 76-year-old client is brought to the clinic by his daughter. The daughter states that her father has had two transient ischemic attacks (TIAs) in the past week. The physician orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option does the nurse expect the physician to offer this client to increase blood flow to the brain?

Carotid endarterectomy

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

The nurse is caring for a client with aphasia. Which strategy will the nurse use to facilitate communication with the client?

Establishing eye contact

How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tPA)?

Every 15 minutes

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

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

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

Heparin sodium

nystagmus

Involuntary rapid eye movements

A client has experienced an ischemic stroke that has damaged the lower motor neurons of the brain. Which of the following deficits would the nurse expect during assessment?

Lack of deep tendon reflexes

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 of the following findings?

Left-sided cerebrovascular accident (CVA)

A patient is brought to the emergency department with a possible stroke. What initial diagnostic test for a stroke, usually performed in the emergency department, would the nurse prepare the patient for?

Noncontrast computed tomogram

A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention?

Place the bedside table on the right side of the bed

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:

Right-sided paralysis.

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are:

Severe headache and early change in level of consciousness

homonymous hemianopsia

The loss of the right or left half of the field of vision in both eyes.

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 hospitalized when presenting to the emergency department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to his presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what?

Transient ischemic attack (TIA)

global aphasia

When both production and understanding of language is damaged

The nurse is discharging home a patient who suffered a stroke. The patient has a flaccid right arm and leg and is experiencing problems with urinary incontinence. The nurse makes a referral to the home health nurse because the hospital nurse is aware that the most common patient response to a change in body image is what?

depression

diplopia

double vision

Which disturbance results in loss of half of the visual field?

homonymous hemianopsia

A nurse is assessing a client. Which of the following findings indicates that the client has experienced a left-hemispheric stroke?

inability to recognize familiar objects

The nurse is caring for a client diagnosed with a hemorrhagic stroke. The nurse recognizes that which intervention is most important?

maintaining a patient airway

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

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

carotid endarterectomy

surgical removal of atherosclerotic plaque

anisocoria

unequal pupil size