PrepU 67
Form words that are understandable or comprehend spoken words
A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to perform which action?
impaired swallowing
A diagnostic test has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include honey thickened liquids. Which of the following is the priority nursing diagnosis for this client?
Left-sided hemiplegia Tendency to distractibility Neglect of objects and people on the left side
A family member comes to the clinic to talk to the nurse about a 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.
Heparin sodium
A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question?
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?
every 15 min
How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tPA)?
aspirin
If warfarin is contraindicated as a treatment for stroke, which medication is the best option?
Cardiogenic emboli.
Left Atrium complication, AFIB
ischemic
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?
Semi-Fowler's
The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient?
smoke
The nurse is participating in a health fair for stroke prevention. Which will the nurse say is a modifiable risk factor for ischemic stroke?
Weakness on one side of the body and difficulty with speech
The nurse is providing information about strokes to a community group. Which of the following would the nurse identify as the primary initial symptoms of an ischemic stroke?
Left visual field deficit
What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke?
dysphagia
difficulty swallowing
dyspraxia
difficulty with planing movements, especially complex or new movements
aphasia
impairment of language, usually caused by left hemisphere damage either to Broca's area (impairing speaking) or to Wernicke's area (impairing understanding).
Agraphia
inability to write
4pm
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?
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?
1 to 3 days
A patient is in the acute phase of an ischemic stroke. How long does the nurse know that this phase may last?
A transient ischemic attack (TIA)
is a neurologic deficit typically lasting less than 1 hour. A TIA is manifested by a sudden loss of motor, sensory, or visual function. The symptoms result from temporary ischemia (impairment of blood flow) to a specific region of the brain; however, when brain imaging is performed, there is no evidence of ischemia.
agnosia
the inability to recognize familiar objects. Which term refers to the failure to recognize familiar objects perceived by the senses?
Increased urine output
A client is receiving an IV infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To confirm that this drug is producing its therapeutic effect, the nurse should consider which finding most significant?
Hemorrhage
A critical care nurse is caring for a client with a cerebrovascular accident (CVA) The client is prescribed heparin for treatment. The nurse knows to monitor the client for what adverse effects?
First 2 to 12 hours
Aneurysm rebleeding occurs most frequently during which time frame after the initial hemorrhage?
Face the client and establish eye contact.
A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take?
3hrs
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?
Left-sided cerebrovascular accident (CVA)
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?
frontal
A stroke victim is experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe?
Psychosis, disorientation, delirium, insomnia, and hallucinations
The nurse is caring for a client following an aneurysm coiling procedure. The nurse documents that the client is experiencing Korsakoff syndrome. Which set of symptoms characterizes Korsakoff syndrome?
Transcranial Doppler (TCD)
Which of the following diagnostics are beneficial to detect intracranial stenosis?
bleeding
Which of the following is the most common side effect of tissue plasminogen activator (tPA)?
Atrial fibrillation
Which of the following, if left untreated, can lead to an ischemic stroke?
Apraxia
Which term refers to the inability to perform previously learned purposeful motor acts on a voluntary basis?
Diastolic pressure of 110 mm Hg
After the patient has received tPA, the nurse knows to check vital signs every 30 minutes for 6 hours. Which of the following readings would require calling the provider?
cardio embolic
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?
Remove throw rugs and electrical cords from home environment.
The geriatric advanced practice nurse (APN) is doing client teaching with a client who has had a cerebrovascular accident (CVA) and the client's family. One concern the APN addresses is a potential for falls related to the CVA and resulting muscle weakness. What would be most important for the APN to include in teaching related to this concern?
Provide a dimly lit environment. Elevate the head of bed 30 degrees. Administer docusate per order.
The nurse is caring for a client diagnosed with a subarachnoid hemorrhage resulting from a leaking aneurysm. The client is awaiting surgery. Which nursing interventions would be appropriate for the nurse to implement? Select all that apply.
Migraines often coincide with menstrual cycle.
A client who complains of recurring headaches, accompanied by increased irritability, photophobia, and fatigue is asked to track the headache symptoms and occurrence on a calendar log. Which is the best nursing rationale for this action?
Noncontrast computed tomography (CT)
Which of the following is the initial diagnostic in suspected stroke?
Carotid endarterectomy
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?
Auditory agnosia
A client has experienced an ischemic stroke that has damaged the temporal (lateral and superior portions) lobe. Which of the following deficits would the nurse expect during assessment of this client?
This is significant for poor neurologic outcomes.
A patient having an acute stroke with no other significant medical disorders has a blood glucose level of 420 mg/dL. What significance does the hyperglycemia have for this patient?
cerebral aneurism
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?
Lioresal (Baclofen)
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?
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?
"Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation."
During a class on stroke, a junior nursing student asks what the clinical manifestations of stroke are. What would be the instructor's best answer?
From the left side of the client
From which direction should a nurse approach a client who is blind in the right eye?
The day the patient has the stroke
When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke?
Homonymous hemianopsia
Which disturbance results in loss of half of the visual field?
Assist the client with meals. Test the gag reflex before offering food or fluids. Allow ample time to eat.
Which interventions would be recommended for a client with dysphagia? Select all that apply.
Intracranial hemorrhage
Which is a contraindication for the administration of tissue plasminogen activator (t-PA)?
apraxia
inability to organize movement Which term refers to the inability to perform previously learned purposeful motor acts on a voluntary basis?
impaired cerebral circulation
A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the health care provider in the emergency department. Which is the origin of the client's symptoms?
Balloon angioplasty of the carotid artery followed by stent placement Carotid endarterectomy
A 76-year-old male 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? Select all that apply.
Establish eye contact
The nurse is caring for a client with aphasia. Which strategy will the nurse use to facilitate communication with the client?
Keeping the client in one position to decrease bleeding
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?
Limited attention span and forgetfulness
A client has experienced an ischemic stroke that has damaged the frontal lobe of his brain. Which of the following deficits does the nurse expect to observe during assessment?
Brain CT scan or MRI
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?
Blood pressure control Weight loss Smoking cessation
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.
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?
Anticoagulant therapy
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?
immediately
A client's spouse relates how the client reported a severe headache and then was unable to talk or move their right arm and leg. After diagnostics are completed and the client is admitted to the hospital, when would basic rehabilitation begin?
Impaired Swallowing
A diagnostic test has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include honey thickened liquids. Which of the following is the priority nursing diagnosis for this client?
spouse
A nurse in a rehabilitation facility is coordinating the discharge of a client who is tetraplegic. The client, who is married and has two children in high school, is being discharged to home and will require much assistance. Who would the discharge planner recognize as being the most important member of this client's care team?
"Emotional lability is common after a stroke, and it usually improves with time."
A nurse is instructing the spouse of a client who suffered a stroke about the use of eating devices the client will be using. During the teaching, the spouse starts to cry and states, "One minute he is laughing, and the next he's crying; I just don't understand what's wrong with him." Which statement is the best response by the nurse?
Thrombolytic therapy has a time window of only 3 hours.
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?
3 hrs
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?
International normalized ratio greater than 2
An emergency department nurse is interviewing a client who is presenting with signs of an ischemic stroke that began 2 hours ago. The client reports a history of a cholecystectomy 6 weeks ago and is taking digoxin, warfarin, and labetalol. What factor poses a threat to the client for thrombolytic therapy?
Placing food on the affected side of the mouth
The nurse is caring for a client with dysphagia. Which intervention would be contraindicated while caring for this client?
1 hr
The nurse knows that symptoms associated with a TIA, usually a precursor of a future stroke, usually subside in what period of time?
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:
Cardiogenic emboli
The provider diagnoses the patient as having had an ischemic stroke. The etiology of an ischemic stroke would include which of the following?
gender
Which is a nonmodifiable risk factor for ischemic stroke?
Noncontrast computed tomography (CT).
Which of the following is the initial diagnostic in suspected stroke?