Quiz #4

A patient is admitted to the hospital with a diagnosis of transient ischemic attack (TIA). The patient asks the nurse to explain to him what a TIA is. Which statement by the nurse is most accurate?

A TIA can be the first warning sign of a stroke

What does the nurse know about the stroke patient who has receptive aphasia?

Has difficulty comprehending written communication

The nurse is collecting neurological data on a post stroke adult client. Which techniques should the nurse perform to adequately check proprioception?

Hold the sides of the client's great toe, and while moving it, ask what position it is in.

A right-handed patient has right-sided hemiplegia and aphasia from a stroke. What is the most likely location of the lesion?

Left frontal lobe

The nurse is caring for a client with a diagnosis of right (nondominant) hemispheric brain attack. The nurse notes that the client is alert and oriented to time and place. Based on these findings, the nurse makes which determination?

The client may have perceptual and spatial disabilities

A patient has a recently suffered a stroke with left-sided weakness and has problems with choking, especially when drinking thin liquids. What nursing interventions would be most helpful in assisting this patient to swallow safely?

Tuck chin when swallowing

The nurse is trying to communicate with a stroke client with aphasia. Which actions by the nurse would be included in the plan of care? Select all that apply

-Allow plenty of time for the client to respond -Speak slowly and distinctly -Establish eye contact during attempts at speech -Complete the sentence that the client cannot finish

Which of the following techniques are necessary for safely feeding a hemiplegic patient? Select all that apply

-Monitor gag reflex -Thicken liquids with a commercially available thickening agent -Use training cup for fluids as necessary

The nursing assessment of an 80-year-old who has had a stroke found that she had difficulty swallowing. A video fluoroscopy with barium was performed to rule out aspiration. The rehabilitation team in the skilled nursing facility determined that she can eat a soft diet with one-to-one supervision. Which action is important to prevent aspiration?

-Tipping the head towards the unaffected side while swallowing

The nurse is aware that the drug t-PA (Activase), a tissue plasminogen activator, must be given in____hours of the onset of symptoms to have maximum benefit

3

An 72-year-old patient has had a stroke. He is left-handed and has a history of hypertension and "mini" strokes. He presents with right hemiplegia. To afford him the best visual field, the nurse should approach him:

from the left side