Chapter 38, Caring for Clients With Cerebrovascular Disorders

Following the use of a thrombolytic agent in the management of cerebrovascular accident (CVA) client, which is the priority nursing assessment? A) Pulse B) Respirations C) Airway D) Blood pressure

Ans: D Feedback: The use of tissue plasminogen activator (TPA), a thrombolytic agent, has been found to limit the neurologic deficits when given within 3 hours after onset of an ischemic CVA.

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? A) Unilateral ptosis B) Respiratory distress C) Severe headache D) Nausea and vomiting

Ans: A Feedback: A client with a TIA may experience impaired muscle coordination or paralysis on one side. Respiratory distress and severe headache are not associated with TIA. Nausea and vomiting is not a usual symptom of TIA.

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? A) Avoid heavy lifting. B) Avoid fiber in the diet. C) Take an antacid frequently. D) Take an herbal form of feverfew.

Ans: A Feedback: A client with an aneurysm should be advised to avoid heavy lifting, extreme emotional situations, or straining of stools because these activities increase intracranial pressure and thereby headaches and potential rupture of aneurysm.

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? A) Ischemic B) Hemorrhagic C) Right-sided D) Left-sided

Ans: A Feedback: Ischemic strokes occur when a thrombus or embolus obstructs an artery carrying blood to the brain; about 80% of strokes are the ischemic variety. Options B, C, and D are incorrect.

A client has tension headaches. The nurse recommends massage as a treatment for tension headaches. How does massage help clients with tension headaches? A) Reduces hypotension B) Increases appetite C) Relaxes muscles D) Relieves migraines

Ans: C Feedback: 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.

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) A unit of fresh frozen plasma is infusing. B) Neurological checks are ordered every 2 hours. C) Keppra is ordered for treatment of focal seizures. D) Oropharyngeal suctioning as needed.

Ans: A Feedback: FFP is used in the treatment of clotting deficiencies as seen with over dose of anticoagulants and would indicate a hemorrhagic stroke.

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? A) "I use this to prevent migraines." B) "I take this when I get a headache." C) "It constricts the blood vessels in my head." D) "It alleviates my sensitivity to light and sound."

Ans: A Feedback: Imitrex is a serotonin receptor agonist that stimulates serotonin receptors in the brain and causes vasoconstriction of the cerebral arteries and reduce/eliminate headaches and other symptoms associated with migraines.

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? A) Avoid crowds. B) Take drugs only after meals at night. C) Avoid caffeine and alcohol. D) Use caution while driving or performing hazardous activities.

Ans: D Feedback: A client who is prescribed a neuronal stabilizer needs to exercise caution while driving and avoid performing hazardous activities.

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? A) To prevent contractures and joint deformities B) To decrease risk for ineffective cerebral tissue perfusion C) To develop appropriate coping mechanisms D) To increase activity tolerance

Ans: A Feedback: The long-term outcome for rehabilitation is directed toward maintaining musculoskeletal functioning.

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? A) Identify and avoid factors that precipitate or intensify an attack. B) Keep a record of activities following an attack. C) When an attack occurs, stay in a brightly lit area. D) Write down any adverse drug effects.

Ans: A Feedback: The nurse includes the following instructions: Follow the indications and dosage regimen for medication and notify the physician of any adverse drug effects.

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? A) Perform a vision field assessment. B) Reposition the tray and plate. C) Assist the client with feeding. D) Know this is a normal finding for CVA.

Ans: A Feedback: The nurse should perform a vision field assessment to evaluate the client for hemianopia. This finding could indicate damage to the visual area of the brain as a result of evolving 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. A) Left-sided hemiplegia B) Tendency to distractibility C) Impairment of long-term memory D) Hyperaware of deficits E) Neglect of objects and people on the left side

Ans: A, B, E Feedback: Left-sided hemiplegia (stroke on right side of brain) may have the following neurologic deficits: spatial-perceptual defects; disregard for the deficits of the affected side require special safety considerations

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. A) Red wine B) Nausea C) Menstruation D) Exposure to bright light E) Change in environmental temperature F) Prolonged positioning

Ans: A, C Feedback: Research on the cause of migraines is ongoing; however, changes in reproductive hormones (menstruation) and particular food/beverages can be a trigger for some clients. Nausea is a symptom of a migraine.

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. A) Balloon angioplasty of the carotid artery followed by stent placement B) Removal of the carotid artery C) Percutaneous transluminal coronary artery angioplasty D) Carotid endarterectomy

Ans: A, D Feedback: If narrowing of the carotid artery by atherosclerotic plaques is the cause of the TIAs, a carotid endarterectomy (surgical removal of atherosclerotic plaque) could be performed.

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? A) Wheelchair placed so client leads with his left side B) Wheelchair placed on the right side of the bed facing the foot C) Wheelchair placed on the left side of the bed facing the head D) Wheelchair placed on the right side of the bed facing the head

Ans: B Feedback: A right-sided brain infarct can result in left-sided weakness or paralysis. The wheelchair should be positioned to allow the client to lead with the right side of the body.

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? A) Cholesterol-lowering drugs B) Anticoagulant therapy C) Monthly prothrombin levels D) Carotid endarterectomy

Ans: B Feedback: Anticoagulant or antiplatelet therapy can prevent clot formation associated with cardiac dysrhythmias such as atrial fibrillation.

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? A) Cluster headaches can cause severe debilitating pain. B) Migraines often coincide with menstrual cycle. C) Tension headaches are easier to treat. D) Headaches are the most common type of reported pain.

Ans: B Feedback: Changes in reproductive hormones as found during menstrual cycle can be a trigger for migraine headaches and may assist in the management of the symptoms.

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? A) Becomes confused during the night B) Drooling from side of mouth C) Bruit heard over carotids D) Irregular heart rhythm

Ans: B Feedback: Facial droop and drooling from the side of the mouth can indicate progression of symptoms or evolving CVA.

Which nursing assessment finding is most indicative of a hemorrhagic stroke? A) Client history of atrial fibrillation B) Sudden onset of breathing alterations C) Symptoms evolving over 24 to 48 hours D) Client history of hyperlipidemia

Ans: B Feedback: Hemorrhagic strokes are less common than ischemic strokes and usually present with sudden onset and have the most impact on breathing, blood pressure, and heart rate.

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? A) Therapeutic range is achieved. B) Coumadin will be increased. C) Coumadin will be decreased. D) INR is too high.

Ans: B Feedback: Ideally, the INR will be therapeutic at 2.0 to 3.0. Because the level is low, the nurse can anticipate the increase in Coumadin dosage.

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) Transient ischemic attack (TIA) B) Left-sided cerebrovascular accident (CVA) C) Right-sided cerebrovascular accident (CVA) D) Completed Stroke

Ans: B Feedback: 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.

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. A) The symptoms are no longer evolving. B) Presence of an ischemic stroke C) Used concurrently with heparin therapy D) Administer intramuscular for faster response. E) Administer within 3 hours of onset of symptoms. F) Administer for hemorrhagic strokes.

Ans: B, E Feedback: TPA is a thrombolytic agent that can limit neurologic deficits if given IV within 3 hours of onset of an ischemic CVA.

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? A) Migraine B) Tension C) Cluster D) Sinus

Ans: C Feedback: A person with a cluster headache has pain on one side of the head, usually behind the eye, accompanied by nasal congestion, rhinorrhea (watery discharge from the nose), and tearing and redness of the eye.

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? A) The interaction may cause the client to become violent. B) The interaction may cause migraine in the client. C) The stimulation can increase intracranial pressure (ICP) or trigger a seizure. D) The client may become emotional and lose interest in the treatment.

Ans: C Feedback: Although visitors' and family members' desire to interact with the client are well intentioned, the stimulation can increase ICP or trigger a seizure.

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? A) Prothrombin level B) Chest x-ray C) Brain CT scan or MRI D) Lumbar puncture

Ans: C Feedback: CT scan or MRI differentiates CVA from other disorders and can differentiate between ischemic or hemorrhagic strokes.

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? A) Occupational therapy daily B) Use of walker for ambulation C) Use of high-top tennis shoes throughout the day D) Whirlpool tub baths and massage therapy

Ans: C Feedback: Hemiplegic clients are at risk for the development of plantar flexion, which would impede ambulation. High-top tennis shoes act as splints, providing support to the ankle/foot, and prevent plantar flexion contractures by maintaining the extremity in proper anatomic position.

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? A) Risk for Fluid Volume Deficit B) Risk for Aspiration C) Impaired Swallowing D) Altered Nutrition: Less Than Body Requirements

Ans: C Feedback: Impaired Swallowing was evident on the video fluoroscopy. Risk for Aspiration, Altered Nutrition, and Fluid Volume Deficit can occur but are not the primary diagnosis at this point in time.

A client is admitted for evaluation of cerebral aneurysm. Which assessment finding is of greatest importance in prioritizing nursing care to this client? A) Complaint of headache off and on for past month B) No bowel movement since yesterday C) Nausea D) Frequent voiding

Ans: C Feedback: Nausea needs to be controlled to prevent vomiting, which can greatly increase the intracranial pressure and subsequently rupture the aneurysm.

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? A) Encourage deep breathing and coughing. B) Observe for facial swelling. C) Anticipate need for endotracheal intubation. D) Resume antilipemic drugs.

Ans: C Feedback: Surgical approach to the neck area can result in swelling and blockage of the airway. This is especially significant with bilateral carotid endarterectomy.

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? A) Blood pressure 180/98 mm Hg B) Alert and oriented times three C) Grade V on the Hunt-Hess Scale D) Complaint of severe splitting headache

Ans: C Feedback: The Hunt-Hess Scale is used for grading a client with a cerebral aneurysm and provides the most accurate assessment as listed.

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? A) Fish, meats, and vegetable oils B) Citrus fruits C) Milk and dairy products D) Cereals, soybeans, and spinach

Ans: D Feedback: Clients who take warfarin (Coumadin) must be informed that they should avoid foods rich in vitamin K. Examples of food sources of vitamin K include cabbage, cauliflower, spinach, and other green leafy vegetables; cereals; and soybeans.

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? A) "Don't worry. The aneurysm has probably been there since birth." B) "The headache can be an indication that the aneurysm is growing." C) "A headache means your aneurysm is leaking blood into the brain." D) "Your physician wants to evaluate the location and condition of the aneurysm."

Ans: D Feedback: Keeping the client calm and quiet is an important aspect of care. Explaining the need for further evaluation is factual.

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? A) "I sense that you are happy it was not a stroke." B) "People who experience a TIA will develop a stroke." C) "TIA symptoms are short lived and resolve within 24 hours." D) "TIA is a warning sign. Let's talk about lowering your risks."

Ans: D Feedback: TIA is a warning sign and can be used to empower clients to make life changes to lower the risks. Sensing the client is happy is a psychotherapeutic response but does not lead to teaching and learning for health promotion.

When providing teaching to a client who reports tension headaches, which of the following instructions would be most beneficial to prevent onset of symptoms? A) Apply cool or warm cloth to head or eyes. B) Eliminate use of bright lights when working. C) Avoid certain foods. D) Perform stretching exercises and frequent position change.

Ans: D Feedback: Tension headaches are often associated with prolonged tensed muscles. Application of cool or warm cloths and avoidance of bright lights may help to reduce the headache after occurrence.