Ch. 67: Management of Patients with Cerebrovascular Disorders
Which of the following terms refer to the failure to recognize familiar objects perceived by the senses? a) Agraphia b) Perseveration c) Agnosia d) Apraxia
Agnosia Auditory agnosia is failure to recognize significance of sounds.
A physician orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? a) Dexamethasone (Decadron) b) Heparin sodium c) Phenytoin (Dilantin) d) Methyldopa (Aldomet)
Heparin sodium Administering heparin, an anticoagulant, could increase the bleeding associated with hemorrhagic stroke. Therefore, the nurse should question this order to prevent additional hemorrhage in the brain
Which of the following is the initial diagnostic in suspected stroke? a) Cerebral angiography b) Magnetic resonance imaging (MRI) c) Noncontrast computed tomography (CT) d) CT with contrast
Noncontrast computed tomography (CT) An initial head CT scan will determine whether or not the patient is experiencing a hemorrhagic stroke. An ischemic infarction will not be readily visible on initial CT scan if it is performed within the first few hours after symptoms onset; however, evidence of bleeding will almost always be visible.
A client has tension headaches. The nurse recommends massage as a treatment for tension headaches. How does massage help clients with tension headaches? a) Relieves migraines b) Relaxes muscles c) Reduces hypotension d) Increases appetite
Relaxes muscles Massaging relaxes tense muscles, causes local dilation of blood vessels, and relieves headache. However, this approach is not likely to help a client with migraine or cluster headaches. Massage is not offered to clients with tension headaches to increase their appetite or reduce hypotension
A patient is exhibiting classic signs of a hemorrhagic stroke. What complaint from the patient would be an indicator of this type of stroke? a) Dizziness and tinnitus b) Numbness of an arm or leg c) Severe headache d) Double vision
Severe headache The patient with a hemorrhagic stroke can present with a wide variety of neurologic deficits, similar to the patient with ischemic stroke. The conscious patient most commonly reports a severe headache.
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? a) Tachycardia, tachypnea, and hypotension b) Nausea, vomiting, and profuse sweating c) Hemiplegia, seizures, and decreased level of consciousness (LOC) d) Difficulty breathing or swallowing
Hemiplegia, seizures, and decreased level of consciousness (LOC) Spasm or occlusion of a cerebral vessel by a clot causes signs and symptoms similar to those of a stroke: hemiplegia, seizures, decreased LOC, aphasia, hemiparesis, and increased focal symptoms.
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? a) Left-sided cerebrovascular accident (CVA) b) Right-sided cerebrovascular accident (CVA) c) Completed Stroke d) Transient ischemic attack (TIA)
Left-sided cerebrovascular accident (CVA) When the infarct is on the left side of the brain, the symptoms are likely to be on the right, and the speech is more likely to be involved. If the MRI reveals an infarct, TIA is no longer the diagnosis.
The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient? a) Semi-Fowler's b) Supine c) High-Fowler's d) Prone
Semi-Fowler's The head of the bed is elevated 15 to 30 degrees (semi-Fowler's position) to promote venous drainage and decrease intracranial pressure.
Which of the following is accurate regarding a hemorrhagic stroke? a) It is caused by a large-artery thrombosis. b) One of the main presenting symptoms is numbness or weakness of the face. c) Main presenting symptom is an "exploding headache." d) Functional recovery usually plateaus at 6 months.
Main presenting symptom is an "exploding headache." One of hemorrhagic stroke's main presenting symptom is an "exploding headache." In ischemic stroke, functional recovery usually plateaus at 6 months; it may be caused by a large artery thrombosis and may have a presenting symptoms of numbness or weakness of the face.
The nurse is taking care of a client with a headache. In addition to administering medications, the nurse takes measures to assist the client in reducing the pain associated with his headache. Which of the following appropriate nursing interventions may be provided by the nurse to assist this client in reducing or eliminating his pain? a) Apply warm or cool cloths to the forehead or back of the neck. b) Use pressure-relieving pads or a similar type of mattress. c) Maintain hydration by drinking eight glasses of fluid a day. d) Perform the Heimlich maneuver.
Apply warm or cool cloths to the forehead or back of the neck. Warmth promotes vasodilation; cool stimuli reduce blood flow. This will not reduce or eliminate the pain associated with this headache.
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? a) Hemiplegia or hemiparesis b) Limited attention span and forgetfulness c) Visual and auditory agnosia d) Lack of deep tendon reflexes
Limited attention span and forgetfulness Damage to the frontal lobe may impair learning capacity, memory, or other higher cortical intellectual functions. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and a lack of motivation
The nurse is caring for a patient diagnosed with a hemorrhagic stroke. The nurse recognizes that which of the following interventions is most important? a) Maintaining a patent airway b) Elevating the head of the bed at 30 degrees c) Administering a stool softener d) Monitoring for seizure activity
Maintaining a patent airway Maintaining the airway is the most important nursing intervention. Immediate complications of a hemorrhagic stroke include cerebral hypoxia, decreased cerebral blood flow, and extension of the area of injury. Providing adequate oxygenation of blood to the brain minimizes cerebral hypoxia. Brain function depends on delivery of oxygen to the tissues. Administering supplemental oxygen and maintaining the hemoglobin and hematocrit at acceptable levels will assist in maintaining tissue oxygenation.
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? a) A ruptured arteriovenous malformation will cause deficits until it is stopped. b) Intracranial pressure is increased by a space-occupying bleed. c) A ruptured intracranial aneurysm must quickly be repaired. d) Thrombolytic therapy has a time window of only 3 hours.
Thrombolytic therapy has a time window of only 3 hours. Currently approved thrombolytic therapy for ischemic strokes has a treatment window of only 3 hours after the onset of symptoms. Urgency is needed on the part of the public for rapid entry into the medical system.
Which of the following is the chief cause of intracerebral hemorrhage (ICH)? a) Diabetes b) Uncontrolled hypertension c) Migraine headaches d) Hypercholesterolemia
Uncontrolled hypertension Primary intracerebral hemorrhage (ICH) from a spontaneous rupture of small arteries or arterioles accounts for approximately 80% of hemorrhagic strokes and is caused chiefly by uncontrolled hypertension.
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? a) Install a bed alarm to remind the client to ask for assistance and to alert staff that the client is getting out of bed. b) Encourage the client to do as much as possible without assistance, and to use the call light only in emergencies. c) Encourage the family to reprimand the client if he doesn't ask for help with transfers and mobility. d) 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. The bed alarm will alert staff that the client is attempting to transfer, so they can come to assist.
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? a) "Clinical manifestations of a stroke generally include aphasia, one-sided flaccidity, and trouble swallowing." b) "Clinical manifestations of a stroke are highly variable, depending on the cardiovascular health of the client." c) "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." d) "Clinical manifestations of a stroke depend on how quickly the clot can be dissolved."
"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." Clinical manifestations following a stroke are highly variable and depend on the area of the cerebral cortex and the affected hemisphere, the degree of blockage (total, partial), and the presence or absence of adequate collateral circulation. (Collateral circulation is circulation formed by smaller blood vessels branching off from or near larger occluded vessels.)
A client has just been diagnosed with an aneurysm. In planning discharge teaching for this client, what instructions should be delivered by the nurse to the client? a) Take opioid analgesics. b) Avoid heavy lifting. c) Take an herbal form of feverfew. d) Include peanut butter, bread, or tart foods in the diet.
Avoid heavy lifting. A client with an aneurysm should be advised to avoid heavy lifting, extreme emotional situations, or straining of stools because they may increase intracranial pressure and thereby headaches.
A 73-year-old client is visiting the neurologist. The 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? a) TIA b) Diplopia c) Atherosclerotic plaque d) Bruit
Bruit A neurologic examination during an attack reveals neurologic deficits. Auscultation of the artery may reveal a bruit (abnormal sound caused by blood flowing over a rough surface within one or both carotid arteries). The term for the auscultated discovery is bruit.
The nurse is caring for a patient with aphasia. Which of the following strategies will the nurse use to facilitate communication with the patient? a) Speaking loudly b) Avoiding the use of hand gestures c) Establishing eye contact d) Speaking in complete sentences
Establishing eye contact The following strategies should be used by the nurse to encourage communication with a patient with aphasia: face the patient and establish eye contact, speak in your usual manner and tone, use short phrases, and pause between phrases to allow the patient time to understand what is being said; limit conversation to practical and concrete matters; use gestures, pictures, objects, and writing; and as the patient uses and handles an object, say what the object is. It helps to match the words with the object or action, be consistent in using the same words and gestures each time you give instructions or ask a question, and keep extraneous noises and sounds to a minimum. Too much background noise can distract the patient or make it difficult to sort out the message being spoken.
