M/S Chapter 38

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"

"I use this to prevent migraines"

A client who has experienced an initial transient ischemic attack (TIA) states: "I'm glad it wasn't anything serious", which is the best response by the nurse to this statement? A) "I sense that you are happy it wasn't a stroke" B) "People who experience a TIA will develop a stroke" C) "TIA symptoms are short lived and resolve within 24h" D) "TIA is a warning sign, let's talk about lowering your risk"

"TIA is a warning sign, let's talk about lowering your risk"

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 a cerebral aneurysm? A) "Don't worry, the aneurysm has probably been there since birth" B) "The headache can be an indication that the aneurysm is growing" C) "A headache means your aneurysm is leaking blood into the brain" D) "Your physician wants to evaluate the location and condition of the aneurysm"

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

A client has experienced a 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

Anticipate need for endotracheal inthbation

A client with a history of atrial fibrillation has experienced a TIA. In an effort to reduce the risk of cerebrovascular accident (CVA), the nurse anticipates the priority medical treatment to include which of the following? A) Cholesterol-lowering drugs B) Anticoagulant therapy C) Monthly prothrombin levels D) Carotid endarterectomy

Anticoagulant therapy

A client presents to the walk-in clinic complaining of a migraine. The client is prescribed an anti lepton. 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

Avoid caffeine and alcohol

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

Avoid heavy lifting

A 76 yo male client is brought into the clinic by his daughter. The daughter states that the 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? (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

Balloon angioplasty of the carotid artery followed by stent placement and carotid endarterectomy

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 xray C) Brain CT scan or MRI D) Lumbar puncture

Brain CT scan or MRI

While the nurse is making initial rounds after coming on shift, a client thrashes 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 does the nurse suspect the client is having? A) Migraine B) Tension C) Cluster D) Sinus

Cluster

An elderly client who has fallen several times at home is admitted for possible TIA. Which assessment finding is most significant in determining care for this client? A) Becomes confused during the night B) Drooling from side of mouth C) Bruit heard over carotids D) Irregular heart rhythm

Drooling from side of mouth

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) BP 180/98 B) Alert and oriented x3 C) Grade V on the Hunt-Hess scale D) Complaint of severe splitting headache

Grade V on the Hunt-Hess scale

A client diagnosed with migraine headaches asks the nurse what he can do to help control the headaches and minimize the number of attacks he is having. What instructions should the nurse give to 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 affects

Identify and avoid factors that precipitate or intensify an attack

A client is being assessed for a possible TIA. Which of the following assessment findings suggests to the nurse that the client is experiencing a TIA? A) Impaired muscle coordination B) Respiratory distress C) Severe headache D) Nausea and vomiting

Impaired muscle coordination

A diagnostic test has determined that the appropriate diet for the client with a left CVA should include honey thickened liquids. Which of the following is the priority nursing diagnosis for this client? A) Risk for fluid volume deficit B) Risk for electrolyte imbalance C) Impaired swallowing D) Altered nutrition: Less than body requirements

Impaired swallowing

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

Ischemic

A client is admitted with weakness, expressive aphasia and right hemianopia. The brain MRI reveals an infarct. The nurse understand these symptoms to be suggestive of which finding? A) TIA B) Left-sided CVA C) Right-sided CVA D) Completed stroke

Left-sided CVA

A family member comes to the clinic to talk to the nurse about 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

Left-sided hemiplegia, tendency to distractibility, neglect of objects and people on the left side

A client who complained of recurring headaches, accompanied by increased irritability, photophobia and fatigue is asked to track the headache symptoms and occurrence in 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

Migraines often coincide with menstrual cycle

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

Nausea

A client with a 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

Perform a vision field assessment

When providing teaching to a client who reports tension headaches, which of the following instructions would be the most 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 change

Perform stretching exercises and frequent position change

A client has been found unresponsive at home for an undetermined period of time. A 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 of the following? (Select all that apply) A) The symptoms are no longer evolving B) Presence of an ischemic stroke C) Used concurrently with heparin therapy D) Administer intramuscular for faster response E) Administer within 3 hours of onset of symptoms F) Administer for hemorrhagic strokes

Presence of an ischemic stroke and administer within 3 hours of onset of symptoms

The nurse is completing an assessment in a client with a history of migraines. The nurse would identify which of the following factors 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

Red wine, menstruation and exposure to flashing light

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

Relaxes muscles

Which nursing assessment finding is most indicative of a hemorrhagic stroke? A) Client with a history of atrial fibrillation B) Sudden onset of breathing alterations C) Symptoms evolving over 24-48 hours D) Client history of hyperlipidemia

Sudden onset of breathing alterations

The nurse is caring for a client with a cerebral aneurysm. Why does the nurse limit the interaction of visitors or family members for a client with an aneurysm? A) The interaction may cause the client to become violent B) The interaction may cause migraine C) The stimulation can increase intracranial pressure (ICP) or trigger a seizure D) The client may become emotional and lose interest in the treatment

The stimulation can increase intracranial pressure (ICP) or trigger a seizure