Caring for Clients with Cerebrovascular Disorders
A client is prescribed sumatriptan (Imitrex) for the treatment of migraine headache. Which client statement would indicate a need for additional teaching from the nurse?
"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 nursing response to this statement?
"TIA is a warning sign. Let's talk about lowering your risks."
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 to a cerebral aneurysm?
"Your physician wants to evaluate the location and condition of the aneurysm."
A client is prescribed warfarin. Client teaching has included instructions to avoid a diet rich in foods that contain vitamin K. What sources of food should the nurse instruct the client to avoid?
Cereals, soybeans, and spinach
While making your initial rounds after coming on shift, you find a client thrashing about in bed complaining of a severe headache. The client tells you the pain is behind his right eye, which is red and tearing. What type of headache would you suspect this client of having?
Cluster
A client is admitted to the intensive care unit (ICU) with a diagnosis of cerebrovascular accident (CVA). Which assessment by the nurse provides the most significant finding in differentiating between ischemic and hemorrhagic strokes?
A unit of fresh frozen plasma is infusing.
A client has experienced a transient ischemic attack (TIA) and presents with carotid bruits. Which is the priority action to be taken by the nurse, following a bilateral carotid endarterectomy?
Anticipate need for endotracheal intubation
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 medical treatment to include which of the following?
Anticoagulant therapy
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.
Balloon angioplasty of the carotid artery followed by stent placement Carotid endarterectomy
You are caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke do you know this client has?
Ischemic
When providing teaching to a client who reports tension headaches, which of the following instructions would be most beneficial to prevent onset of symptoms?
Perform stretching exercises and frequent position change.
The nurse is completing an assessment on 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.
Red wine Menstruation
A client has tension headaches. The nurse recommends massage as a treatment for tension headaches. How does massage help clients with tension headaches?
Relaxes muscles
A client is being assessed for a possible transient ischemic attack (TIA). Which of the following assessment findings suggests to the nurse that the client is experiencing a TIA?
Unilateral ptosis
A video fluoroscopy 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?
Impaired Swallowing
A client has been found unresponsive at home for an undetermined period of time. A cerebrovascular accident (CVA) is suspected, and the family is demanding a clot buster be used to restore functioning. The nurse knows that successful use of TPA in a client with CVA requires which of the following? Select all that apply.
Presence of an ischemic stroke Administer within 3 hours of onset of symptoms.
Which of the following goals is the priority in the care planning of a client with cerebrovascular accident (CVA) who is being transferred to a rehabilitation unit?
To prevent contractures and joint deformities
A client presents to the walk-in clinic complaining of a migraine. The client is prescribed a neuronal stabilizer. What should the nurse suggest to the client?
Use caution while driving or performing hazardous activities.
The client with hemiplegia is at risk for impaired walking. Which nursing intervention would best assist this client in preventing complications associated with lower extremity impairment?
Use of high-top tennis shoes throughout the day
The nurse is assisting a client, with a right-sided brain infarction, to transfer from the wheelchair to the bed. Which is the best placement of the wheelchair to facilitate this transfer?
Wheelchair placed on the right side of the bed facing the foot
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?
Avoid heavy lifting.
Following the use of a thrombolytic agent in the management of cerebrovascular accident (CVA) client, which is the priority nursing assessment?
Blood pressure
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?
Brain CT scan or MRI
A client with atrial fibrillation is placed on Coumadin to reduce the potential of developing a cerebrovascular accident (CVA). The international normalized ratio (INR) is 1.5. What does this finding indicate to the nurse?
Coumadin will be increased.
An elderly client, who has fallen several times at home, is admitted for possible transient ischemic attack (TIA). Which assessment finding is most significant in determining care for this client?
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?
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 this client?
Identify and avoid factors that precipitate or intensify an attack.
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?
Left-sided cerebrovascular accident (CVA)
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.
Left-sided hemiplegia Tendency to distractibility Neglect of objects and people on the left side
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?
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?
Nausea
A client with a cerebrovascular accident (CVA) is having difficulty with eating food on the plate. Which is the best nursing action to be taken?
Perform a vision field assessment.
Which nursing assessment finding is most indicative of a hemorrhagic stroke?
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 with the client with an aneurysm?
The stimulation can increase intracranial pressure (ICP) or trigger a seizure.
