405 W8 Chronic Neuro

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?

Reduce hypertension and high blood cholesterol Explanation: CVAs are prevented by reducing certain risk factors, such as hypertension, overweight, cardiac dysrhythmias like atrial fibrillation, and high blood cholesterol. Clients should not gain body weight. In addition, increased intake of proteins, carbohydrates, or fluids does not help reduce the risk of CVAs. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Chart 67-2, p. 2014.

The nurse is caring for a client with a cerebral aneurysm. Why does the nurse limit the interaction of visitors or family members with the client who has an aneurysm?

The stimulation can increase intracranial pressure (ICP) or trigger a seizure. Although visitors' and family members' desire to interact with the client are well intentioned, the stimulation can increase ICP or trigger a seizure. The nurse can suggest that they take turns and stay briefly. Interactions are not likely to make the clients violent or emotional, which may cause the client to lose interest in the treatment. The interactions also may not cause migraine in the client. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Implementing Aneurysm Precautions., p. 2029.

A nurse is completing discharge teaching for the client who has left-sided hemiparesis following a stroke. When investigating the client's home environment, the nurse should focus on which nursing diagnosis?

Risk for injury Because of decreased physical mobility, a client with recent left-sided hemiparesis is at risk for falls in the home setting. His ability to cope with the stroke is important, but investigating the home environment doesn't provide information about this nursing diagnosis. Diarrhea and Noncompliance aren't related to the client's home environment. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Promoting Home, Community-based, and Transitional Care, p. 2024.

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?

A client with a CVA who is given heparin should be monitored for hemorrhage and bleeding at the subcutaneous injection site. Respiratory distress, high blood pressure, or migraine attacks are not likely to occur in such a client. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Medical Management, p. 2028. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 2028

A nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform?

Call the physician immediately. The nurse should notify the physician immediately because the headache may be an indication that the aneurysm is leaking. Sitting with the client is appropriate but only after the physician has been notified of the change in the client's condition. The physician will decide whether or not administration of an analgesic is indicated. Informing the nurse manager isn't necessary. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Intracranial (Cerebral) Aneurysm, p. 2026.