Stroke and Increased ICP Quiz (Cox) 31 questions

A client who has experienced an initial transient ischemic attack (TIA) states: "I'm glad it wasn't anything serious." Which is the best nursing response to this statement? "I sense that you are happy it was not a stroke". "People who experience a TIA will develop a stroke". "TIA symptoms are shortlived and resolve within 24 hours". "TIA is a warning sign. Let's talk about lowering your risks."

"TIA is a warning sign. Let's talk about lowering your risks."

Thrombolytic therapy should be initiated within what time frame of an ischemic stroke to achieve the best functional outcome? 3 hours 6 hours 9 hours 12 hours

3 hours

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 40-year-old Caucasian woman A 62-year-old Caucasian woman A 28-year-old pregnant African-American woman

A 60-year-old African-American man

A patient suffering a stroke is having a difficult time swallowing. What would the nurse document this finding as? Ataxia Arthralgia Dysphagia Dysarthria

Dysphagia

Which of the following is the chief cause of intracerebral hemorrhage (ICH)? Uncontrolled hypertension Diabetes Hypercholesterolemia Migraine headaches

Uncontrolled hypertension

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 feeling an emotional loss. He'll eventually start acknowledging you on his left side." "The client is unaware of his left side. You should approach him on the right side." "The client is unaware of his left side. You need to encourage him to interact from this side." "This condition is temporary."

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

A nurse is teaching a community group about modifiable and nonmodifiable risk factors for ischemic strokes. Which of the following is a risk factor that cannot be modified? Hypertension Atrial fibrillation Advanced age Obesity

Advanced age

The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration? Generalized pain Alteration in level of consciousness (LOC) Tonic-clonic seizures Shortness of breath

Alteration in level of consciousness (LOC)

A white female client is admitted to an acute care facility with a diagnosis of stroke. Her history reveals bronchial asthma, exogenous obesity, and iron-deficiency anemia. Which history finding is a risk factor for stroke? Being white Being female Being obese Having bronchial asthma

Being obese

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? Prothrombin level Chest x-ray Brain CT scan or MRI Lumbar puncture

Brain CT scan or MRI

A patient admitted with a stroke is coming to the unit from the emergency department. The nurse assigned to care for the new patient knows that what assessment finding is indicative of a stroke? Difficulty speaking Increase in heart rate Facial edema Electrolyte imbalance

Difficulty speaking

When caring for a client who has had a stroke, a priority is reduction of ICP. What client position is most consistent with this goal? Head turned slightly to the right side Elevation of the head of the bed Position changes every 15 minutes while awake Extension of the neck

Elevation of the head of the bed

The nurse is assessing a client with a suspected stroke. What assessment finding is most suggestive of a stroke? Facial droop Dysrhythmias Periorbital edema Projectile vomiting

Facial droop

Which is a nonmodifiable risk factor for ischemic stroke? Atrial fibrillation Gender Hyperlipidemia Smoking

Gender

A client with a neurological disorder has difficulty swallowing. The nurse should take special care with the client's diet because of a potential risk of imbalanced nutrition. Which measure may be taken by the nurse to ensure that the client's diet allows for easy swallowing? Instruct the client to lie on the bed when eating Offer liquids frequently, in large quantities Help the client sit upright when eating and feed slowly Allow optimum physical activity before meals to expedite digestion

Help the client sit upright when eating and feed slowly

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

Hypertension

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? Contact the appropriate agencies so that they can provide care after discharge. Suggest that the family members speak with the physician about their concerns. 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. The nurse should do nothing because she is responsible only for inpatient care.

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 client with CVA is prescribed medication to treat the disorder. The client wants to know what other measures may help reduce CVA. Which is an accurate suggestion for the client? Increase body weight moderately Reduce hypertension and high blood cholesterol Increase intake of proteins and carbohydrates Increase hydration and the intake of fluids

Reduce hypertension and high blood cholesterol

When developing a care plan for a client who has recently suffered a stroke, a nurse includes the nursing diagnosis Risk for imbalanced body temperature. What is the rationale for this diagnosis? The stroke may have impacted the body's thermoregulation centers. A decreased body temperature will signal the need to cover the client. An elevated temperature indicates cerebellum malfunction. An elevated body temperature indicates infection.

The stroke may have impacted the body's thermoregulation centers.

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

Tissue plasminogen activator (tPA)

Health promotion efforts to decrease the risk for ischemic stroke involve encouraging a healthy lifestyle including eating fish no more than once a month. a low-fat, low-cholesterol diet and increased exercise. a high-protein diet and increased weight-bearing exercise. a low-cholesterol, low-protein diet and decreased aerobic exercise.

a low-fat, low-cholesterol diet and increased exercise.

A physician orders aspirin, 325 mg P.O. daily for a client who has experienced a transient ischemic attack (TIA). The nurse should teach the client that the physician has ordered this medication to: control headache pain. enhance the immune response. prevent intracranial bleeding. reduce the chance of blood clot formation.

reduce the chance of blood clot formation.

A patient diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for what purpose? To decrease cerebral edema To prevent seizure activity that is common following a TIA To prevent a stroke by removing atherosclerotic plaques blocking cerebral flow To determine the cause of the TIA

To prevent a stroke by removing atherosclerotic plaques blocking cerebral flow

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? Migraine attacks Hemorrhage Respiratory distress High blood pressure

Hemorrhage

Which disturbance results in loss of half of the visual field? Homonymous hemianopsia Diplopia Nystagmus Anisocoria

Homonymous hemianopsia

The client has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the client's atmosphere more conducive to communication? Provide a board of commonly used needs and phrases. Have the client speak to loved ones on the phone daily. Help the client complete his or her sentences as needed. Speak in a loud and deliberate voice to the client.

Provide a board of commonly used needs and phrases.

A rehabilitation nurse caring for a client who has had a stroke is approached by the client's family and asked why the client has to do so much for herself when she is obviously struggling. What would be the nurse's best answer? "We are trying to help her be as useful as she possibly can." "The focus on care in a rehabilitation facility is to help the client to resume as much self-care as possible." "We aren't here to care for her the way the hospital staff did; we are here to help her get better so she can go home." "Rehabilitation means helping clients do exactly what they did before their stroke."

"The focus on care in a rehabilitation facility is to help the client to resume as much self-care as possible."

A client with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this client? Passive range-of-motion exercises to prevent contractures Supine positioning Early initiation of physical therapy Absolute bed rest in a quiet, nonstimulating environment

Absolute bed rest in a quiet, nonstimulating environment

A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take? Use one long sentence to say everything that needs to be said. Keep the television on while she speaks. Talk in a louder than normal voice. Face the client and establish eye contact.

Face the client and establish eye contact.

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.

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 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. blood pressure control weight loss smoking cessation

All options are correct.