PrepU Adult 2 Assignment 15

A community health nurse is conducting a workshop for unlicensed care providers who work in a chain of long-term care facilities. The nurse is teaching the participants about the signs and symptoms of stroke. What signs and symptoms should the nurse identify? Select all that apply.

-Confusion -Sudden numbness -Visual disturbances

The nurse should provide nonpharmacologic techniques for pain relief to a client with IICP. Which of the following techniques may the nurse use? Choose all correct options.

-Use guided imagery -Play soothing music

A client is concerned about having had intermittent cluster headaches over the last year. While several medications can be prescribed for the treatment of cluster headaches, which routes are preferred for medication administration of these drugs? Select all that apply.

-inhaled -intramuscular

A client has suffered several migraines per month for the last 4 months. The physician prescribes prophylactic drug therapy. What is the rationale behind this action? Select all that apply.

-possible reduction in frequency of attacks -possible reduction of migraine intensity -possible reduction in migraine duration

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 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 African-American man

A client is following up after a visit to the emergency department where testing indicated that the client had suffered a transient ischemic attack. To prevent the occurrence of a more serious cerebrovascular accident, which lifestyle changes would the neurologist to prescribe?

All options are correct.

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 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 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 client undergoes cerebral angiography for evaluation after an intracranial computed tomography scan revealed a subarachnoid hemorrhage. Afterward, the nurse checks frequently for signs and symptoms of complications associated with this procedure. Which findings indicate spasm or occlusion of a cerebral vessel by a clot?

Hemiplegia, seizures, and decreased level of consciousness (LOC)

An emergency department (ED) nurse has administered an ordered bolus of tissue plasminogen activator (tPA) to a male patient who was diagnosed with stroke. During the administration of tPA, the nurse should prioritize assessments related to what problem?

Hemorrhage

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

Heparin sodium

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:

Hypertension

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

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

Noncontrast computed tomography

Lillian Anderson, a 73-year-old retired dancer, is being seen by a neurologist in the group where you practice nursing. She reports light-headedness, speech disturbance and left-sided weakness which lasted for several hours. The neurologist diagnosed a transient ischemic attack, which caused Ms. Anderson great concern. During your client education with Ms. Anderson you discuss the frequency of TIAs developing into stroke. How many people who suffer TIAs develop CVA?

One-third

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 nurse is providing diet-related advice to a male patient following a cerebrovascular accident (CVA). The patient wants to minimize the volume of food and yet meet all nutritional elements. Which of the following suggestions should the nurse give to the patient about controlling the volume of food intake?

Provide thickened commercial beverages and fortified cooked cereals.

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

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

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 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.

A patient diagnosed with an ischemic stroke should be treated within the first 3 hours of symptom onset with which of the following?

Tissue plasminogen activator (tPA)

Which of the following diagnostics are beneficial to detect intracranial stenosis?

Transcranial Doppler (TCD)

A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the physician in the emergency department. What is the origin of the client's symptoms?

impaired cerebral circulation

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.

The nurse is taking care of a client with a history of headaches. The nurse takes measures to reduce headaches in the client in addition to administering medications. Which of the following appropriate nursing interventions may be provided by the nurse to such a client? Choose the correct option.

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

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

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

Smoking

A 17-year-old client reports frequent headaches and is seeing the physician to determine their cause. In your client education, which type of headache do you indicate is most common?

Tension

A client has been having cluster headaches intermittently over the last year. In an effort to determine the trigger for the cluster headaches, the client has maintained a journal of all oral consumption. What on the list would the nurse suspect could be triggering headaches?

alcoholic beverages

A client reports frequent headaches and is seeing the physician to determine their cause. In client education, which type of headache does the nurse indicate is most common?

tension

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 has a 12-year history of cluster headaches. After the client describes the characteristics of the head pain, the nurse begins to discuss its potential causes. What would the nurse indicate that the origin of the headaches is:

unknown

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.

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.

Which of the following, if left untreated, can lead to an ischemic stroke?

Atrial fibrillation

A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the physician in the emergency department. After completing ordered diagnostic tests, the physician indicates to the client what caused the symptoms that brought him to the hospital. What is the origin of the client's symptoms?

Impaired cerebral circulation

A nurse is planning discharge for a client who experienced right-sided weakness caused by a stroke. During his hospitalization, the client has been receiving physical therapy, occupational therapy, and speech therapy daily. The family voices concern about rehabilitation after discharge. How should the nurse intervene?

Inform the case manager of the family's concern and provide information about the client's current clinical status so appropriate resources can be provided after discharge.

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

What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke?

Left visual field deficit

A woman has been brought to the emergency department (ED) by her distraught husband who believes that she has had a stroke. A rapid assessment by the care team confirms that the husband's suspicions are likely accurate, and the woman is being screened for the possible administration of recombinant tissue plasminogen activator (r tPA). Which of the following factors would contraindicate the use of tPA?

The woman's stroke has a hemorrhagic etiology.

The nurse is performing stroke risk screenings at a hospital open house. Identification of high-risk individuals is the goal of the screenings. The nurse has identified four patients who might be at risk for a stroke. Which patient is likely at highest risk for a stroke?

White man, age 60 with history of uncontrolled hypertension

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

When communicating with a client who has sensory (receptive) aphasia, the nurse should:

use short, simple sentences.

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

If warfarin is contraindicated as a treatment for stroke, which medication is the best option?

Aspirin

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?

Lioresal (Baclofen)