Stroke PrepU- ch 62
A patient presents to the emergency room with complaints of having an "exploding headache" for the last 2 hours. The patient is immediately seen by a triage nurse who suspects the patient is experiencing a stroke. Which of the following is a possible cause based on the characteristic symptom? Large artery thrombosis Cardiogenic emboli Cerebral aneurysm Small artery thrombosis
Cerebral aneurysm Explanation: A cerebral aneurysm is a type of hemorrhagic stroke that is characterized by an exploding headache.
A 45-year-old client presents to the ED reporting trouble speaking and numbness of the right arm and leg. The nurse suspects an ischemic stroke. Which insult or abnormality can cause an ischemic stroke? Intracerebral aneurysm rupture Arteriovenous malformation Trauma Cocaine use
Cocaine use Explanation: Two classifications of ischemic strokes are cryptogenic strokes, which have no known cause, and strokes from other causes, such as illicit drug use, coagulopathies, migraine, and spontaneous dissection of the carotid or vertebral arteries. Cocaine is a potent vasoconstrictor and may result in a life-threatening reaction, even with the individual's first use of the drug. Arteriovenous malformations, trauma, and intracerebral aneurysm are associated with hemorrhagic strokes.
A diagnostic test has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include thickened liquids. Which of the following is the priority nursing diagnosis for this client? Decreased Fluid Volume Risk Aspiration Risk Malnutrition Risk Impaired Swallowing
Impaired Swallowing Explanation: Impaired Swallowing was evident on the video fluoroscopy. Aspiration, Malnutrition, and Decreased Fluid Volume Risk can occur but are not the primary diagnosis at this point in time.
Which is a contraindication for the administration of tissue plasminogen activator (t-PA)? Ischemic stroke Systolic blood pressure less than or equal to 185 mm Hg Intracranial hemorrhage Age 18 years or older
Intracranial hemorrhage Explanation: Intracranial hemorrhage, neoplasm, and aneurysm are contraindications for t-PA. Clinical diagnosis of ischemic stroke, age 18 years or older, and a systolic blood pressure less than or equal to 185 mm Hg are eligibility criteria.
The geriatric advanced practice nurse (APN) is doing client teaching with a client who has had a cerebrovascular accident (CVA) and the client's family. One concern the APN addresses is a potential for falls related to the CVA and resulting muscle weakness. What would be most important for the APN to include in teaching related to this concern? Need for support group due to decreased self image related to restricted mobility. Remove throw rugs and electrical cords from home environment. Use of tripod cane. Leg exercises to strengthen muscle weakness.
Remove throw rugs and electrical cords from home environment. Explanation: Client and family teaching is essential and focuses on the following points: Remove throw rugs, clutter, and electrical cords from the client's home environment to reduce the potential for falls. Although the other interventions may be appropriate, they are not as directly related to reducing fall risk.
Which terms refers to blindness in the right or left half of the visual field in both eyes? Nystagmus Homonymous hemianopsia Diplopia Scotoma
Homonymous hemianopsia Explanation: Homonymous hemianopsia occurs with occipital lobe tumors. Scotoma refers to a defect in vision in a specific area in one or both eyes. Diplopia refers to double vision or the awareness of two images of the same object occurring in one or both eyes. Nystagmus refers to rhythmic, involuntary movements or oscillations of the eyes.
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? Completed Stroke Left-sided cerebrovascular accident (CVA) Right-sided cerebrovascular accident (CVA) Transient ischemic attack (TIA)
Left-sided cerebrovascular accident (CVA) Explanation: 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. There is not enough information to determine if the stroke is still evolving or is complete.
While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are: Confusion or change in mental status Weakness on one side of the body and difficulty with speech Foot drop and external hip rotation Severe headache and early change in level of consciousness
Severe headache and early change in level of consciousness Explanation: The main presenting symptoms for ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body, confusion or change in mental status, and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Foot drop and external hip rotation can occur if a stroke victim is not turned or positioned correctly.
The nurse is caring for a client with aphasia. Which strategy will the nurse use to facilitate communication with the client? Avoiding the use of hand gestures Speaking loudly Speaking in complete sentences Establishing eye contact
Establishing eye contact Explanation: The following strategies should be used by the nurse to encourage communication with a client with aphasia: face the client and establish eye contact, speak in your usual manner and tone, use short phrases, and pause between phrases to allow the client time to understand what is being said; limit conversation to practical and concrete matters; use gestures, pictures, objects, and writing; and as the client 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 client or make it difficult to sort out the message being spoken.
A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem? Pregabalin (Lyrica) Heparin Lioresal (Baclofen) Diphenhydramine (Benadryl)
Lioresal (Baclofen) Explanation: Spasticity, particularly in the hand, can be a disabling complication after stroke. Botulinum toxin type A injected intramuscularly into wrist and finger muscles has been shown to be effective in reducing this spasticity (although the effect is temporary, typically lasting 2 to 4 months) (Teasell, Foley, Pereira, et al., 2012). Other treatments for spasticity may include stretching, splinting, and oral medications such as baclofen (Lioresal).
A client is hospitalized when presenting to the emergency department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to his presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what? Cerebral aneurysm Left-sided stroke Right-sided stroke Transient ischemic attack
Transient ischemic attack Explanation: A transient ischemic attack (TIA) is a sudden, brief attack of neurologic impairment caused by a temporary interruption in cerebral blood flow. Symptoms may disappear within 1 hour; some continue for as long as 1 day. When the symptoms terminate, the client resumes his or her presymptomatic state. The symptoms do not describe a left- or right-sided stroke or a cerebral aneurysm.
The nurse is caring for a client diagnosed with a hemorrhagic stroke. The nurse recognizes that which intervention is most important? Monitoring for seizure activity Administering a stool softener Maintaining a patent airway Elevating the head of the bed to 30 degrees
Maintaining a patent airway Explanation: 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 hemoglobin and hematocrit at acceptable levels will assist in maintaining tissue oxygenation. All other interventions are appropriate, but the airway takes priority. The head of the bed should be elevated to 30 degrees, monitoring the client because of the risk for seizures, and stool softeners are recommended to prevent constipation and straining, but these are not the most important interventions.
A stroke victim is experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe? Temporal Frontal Parietal Occipital
Frontal Explanation: If damage has occurred to the frontal lobe, learning capacity, memory, or other higher cortical intellectual functions may be impaired. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and a lack of motivation.
A nurse is instructing the spouse of a client who suffered a stroke about the use of eating devices the client will be using. During the teaching, the spouse starts to cry and states, "One minute he is laughing, and the next he's crying; I just don't understand what's wrong with him." Which statement is the best response by the nurse? "Emotional lability is common after a stroke, and it usually improves with time." "This behavior is common in clients with stroke. Which does your spouse do more often? Laugh or cry?" "You sound stressed; maybe using some stress management techniques will help." "You seem upset, and it may be hard for you to focus on the teaching, I'll come back later."
"Emotional lability is common after a stroke, and it usually improves with time." Explanation: This is the most therapeutic and informative response. Often, most relatives of clients with stroke handle the physical changes better than the emotional aspects of care. The family should be prepared to expect occasional episodes of emotional lability. The client may laugh or cry easily and may be irritable and demanding or depressed and confused. The nurse can explain to the family that the client's laughter does not necessarily connote happiness, nor does crying reflect sadness, and that emotional lability usually improves with time. The remaining responses are nontherapeutic and do not address the spouse's concerns.
The nurse is preparing to administer tissue plasminogen activator (t-PA) to a patient who weighs 132 lb. The order reads 0.9 mg/kg t-PA. The nurse understands that 10% of the calculated dose is administered as an IV bolus over 1 minute, and the remaining dose (90%) is administered IV over 1 hour via an infusion pump. How many milligrams IV bolus over 1 minute will the nurse initially administer?
5.4 Explanation: The patient is weighed to determine the dose of t-PA. Typically two or more IV sites are established prior to administration of t-PA (one for the t-PA and the other for administration of IV fluids). The dosage for t-PA is 0.9 mg/kg, with a maximum dose of 90 mg. Of the calculated dose, 10% is administered as an IV bolus over 1 minute. The remaining dose (90%) is administered IV over 1 hour via an infusion pump. First, the nurse must convert the patient's weight to kilograms (132/2.2 = 60 kg), then multiply 0.9 mg × 60 kg = 54 mg. Next, the nurse figure out that 10% of 54 mg is 5.4 (54 ×.10). The nurse will initially administer 5.4 mgs IV bolus over 1 minute.
A stroke victim is experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe? Occipital Parietal Temporal Frontal
Frontal Explanation: If damage has occurred to the frontal lobe, learning capacity, memory, or other higher cortical intellectual functions may be impaired. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and a lack of motivation.
A client is receiving an IV infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To confirm that this drug is producing its therapeutic effect, the nurse should consider which finding most significant? Elevated blood pressure Decreased level of consciousness (LOC) Decreased heart rate Increased urine output
Increased urine output Explanation: The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output. A decreased LOC and elevated blood pressure may indicate lack of therapeutic effectiveness. A decreased heart rate doesn't indicate that mannitol is effective.
An emergency department nurse is interviewing a client who is presenting with signs of an ischemic stroke that began 2 hours ago. The client reports a history of a cholecystectomy 6 weeks ago and is taking digoxin, warfarin, and labetalol. What factor poses a threat to the client for thrombolytic therapy? International normalized ratio greater than 2 Surgery 6 weeks ago Taking digoxin Two hour time period of the stroke
International normalized ratio greater than 2 Explanation: The client is at risk for further bleeding if the international normalized ratio is greater than 2. Thrombolytic therapy must be initiated within 3 hours in clients with ischemic stroke. The client is not eligible for thrombolytic therapy if she has had surgery within 14 days. Digoxin and labetalol do not prohibit thrombolytic therapy.
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? Intracranial pressure is increased by a space-occupying bleed. A ruptured intracranial aneurysm must quickly be repaired. A ruptured arteriovenous malformation will cause deficits until it is stopped. Thrombolytic therapy has a time window of only 3 hours.
Thrombolytic therapy has a time window of only 3 hours. Explanation: 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. The other three choices are related to hemorrhagic strokes.
A client with hypercholesterolemia is receiving Lipitor (atorvastatin) to prevent high cholesterol and stroke. The order is for Lipitor 40 mg PO daily. The medication is supplied in 80 mg tabs. How many tabs will the nurse administer to the client?
0.5 Explanation: 40 mg/80 mg = 0.5 tabs.
Which term refers to the inability to perform previously learned purposeful motor acts on a voluntary basis? Agnosia Agraphia Apraxia Perseveration
Apraxia Explanation: Verbal apraxia refers to difficulty forming and organizing intelligible words although the musculature is intact. Agnosia is a failure to recognize familiar objects perceived by the senses. Agraphia refers to disturbances in writing intelligible words. Perseveration is the continued and automatic repetition of an activity or word or phrase that is no longer appropriate.
After the patient has received tPA, the nurse knows to check vital signs every 30 minutes for 6 hours. Which of the following readings would require calling the provider? Systolic pressure of 130 mm Hg Heart rate of 100 Diastolic pressure of 110 mm Hg Respiration of 22
Diastolic pressure of 110 mm Hg Explanation: A diastolic pressure reading of over 105 mm Hg warrants notifying the health care provider. The other choices are within normal range.
Which is a nonmodifiable risk factor for ischemic stroke? Gender Smoking Hyperlipidemia Atrial fibrillation
Gender Explanation: Nonmodifiable risk factors include gender, age, and race. Modifiable risk factors include atrial fibrillation, hyperlipidemia, and smoking.
A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? Dexamethasone Phenytoin Methyldopa Heparin sodium
Heparin sodium Explanation: 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. In a client with hemorrhagic stroke, the healthcare provider may use dexamethasone (Decadron) to decrease cerebral edema and pressure, methyldopa (Aldomet) to reduce blood pressure, and phenytoin (Dilantin) to prevent seizures.
What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke? Aphasia Altered intellectual ability Slow, cautious behavior Left visual field deficit
Left visual field deficit Explanation: A left visual field deficit is a common clinical manifestation of a right hemispheric stroke. Aphasia, slow, cautious behavior, and altered intellectual ability are all clinical manifestations of a left hemispheric stroke.
Which of the following is accurate regarding a hemorrhagic stroke? Functional recovery usually plateaus at 6 months. One of the main presenting symptoms is numbness or weakness of the face. Main presenting symptom is an "exploding headache." It is caused by a large-artery thrombosis.
Main presenting symptom is an "exploding headache." Explanation: 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.
A female client who reports 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? Headaches are the most common type of reported pain. Tension headaches are easier to treat. Cluster headaches can cause severe debilitating pain. Migraines often coincide with menstrual cycle.
Migraines often coincide with menstrual cycle. Explanation: 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. Cluster headaches can cause severe pain but are not the reason for tracking. Tension headaches can be managed but is not associated with a monthly calendar. Headaches are common but not the reason for tracking.
Which clinical manifestation would be exhibited by a client following a hemorrhagic stroke of the right hemisphere? Neglect of the left side Neglect of the right side Inability to move the right arm Expressive aphasia
Neglect of the left side Explanation: This client would have deficits on the left side. Expressive aphasia typically occurs with left-hemisphere stroke.
Which is the initial diagnostic test for a stroke? Carotid Doppler Electrocardiography Transcranial Doppler studies Noncontrast computed tomography
Noncontrast computed tomography Explanation: The initial diagnostic test for a stroke is nonconstrast computed tomography performed emergently to determine whether the event is ischemic or hemorrhagic. Further diagnostics include a carotid Doppler, electrocardiogram, and transcranial Doppler.
The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient? Supine Semi-Fowler's Prone High-Fowler's
Semi-Fowler's Explanation: The head of the bed is elevated 15 to 30 degrees (semi-Fowler's position) to promote venous drainage and decrease intracranial pressure.
Which is a modifiable risk factor for transient ischemic attacks and ischemic strokes? Smoking Thyroid disease Social drinking Advanced age
Smoking Explanation: Modifiable risk factors for TIAs and ischemic stroke include hypertension, diabetes, cardiac disease, smoking, and excessive alcohol consumption. Advanced age, gender, and race are nonmodifiable risk factors for stroke.
The nurse is caring for a client with chronic migraines who is prescribed medication. What drug-related instructions should the nurse give the client? Take medication only during the morning when it's calm and quiet. Take medication as soon as symptoms of the migraine begin. Take medication only when migraine is intense. Take medication just before going to bed at night.
Take medication as soon as symptoms of the migraine begin. Explanation: The nurse reinforces the drug therapy regimen and instructs the client on self-administration of medications. To stop the migraine headache, the nurse stresses the importance of taking medication as soon as symptoms of the migraine begin and not when the migraine intensifies.
Which interventions would be recommended for a client with dysphagia? Select all that apply. Assist the client with meals. Place food on the affected side of the mouth. Test the gag reflex before offering food or fluids. Allow ample time to eat.
Test the gag reflex before offering food or fluids. Allow ample time to eat. Assist the client with meals. Interventions for dysphagia include placing food on the unaffected side of the mouth, allowing ample time to eat, assisting the client with meals, and testing the client's gag reflex before offering food or fluids.
When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke? The day before the patient is discharged After the patient has passed the acute phase of the stroke The day the patient has the stroke After the nurse has received the discharge orders
The day the patient has the stroke Explanation: Although rehabilitation begins on the day the patient has the stroke, the process is intensified during convalescence and requires a coordinated team effort.
A patient having an acute stroke with no other significant medical disorders has a blood glucose level of 420 mg/dL. What significance does the hyperglycemia have for this patient? The patient has developed diabetes insipidus due to the location of the stroke. This is significant for poor neurologic outcomes. The patient has new onset diabetes. The patient has liver failure.
This is significant for poor neurologic outcomes. Explanation: Hyperglycemia has been associated with poor neurologic outcomes in acute stroke and should be treated if the blood glucose is above 140 mg/dL (Summers et al., 2009).
Health promotion efforts to decrease the risk for ischemic stroke involve encouraging a healthy lifestyle including a low-cholesterol, low-protein diet and decreased aerobic exercise. a high-protein diet and increased weight-bearing exercise. a low-fat, low-cholesterol diet and increased exercise. eating fish no more than once a month.
a low-fat, low-cholesterol diet and increased exercise. Explanation: Health promotion efforts to decrease the risk for ischemic stroke involve encouraging a healthy lifestyle including a low-fat, low-cholesterol diet and increased exercise. Recent evidence suggests that eating fish two or more times per week reduces the risk of thrombotic stroke for women.
A client diagnosed with a stroke is ordered to receive warfarin. Later, the nurse learns that the warfarin is contraindicated and the order is canceled. The nurse knows that the best alternative medication to give is ticlopidine. dipyridamole. clopidogrel. aspirin.
aspirin. Explanation: If warfarin is contraindicated, aspirin is the best option, although other medications may be used if both are contraindicated.
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? "Clinical manifestations of a stroke generally include aphasia, one-sided flaccidity, and trouble swallowing." "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 of a stroke depend on how quickly the clot can be dissolved." "Clinical manifestations of a stroke are highly variable, depending on the cardiovascular health of the client."
emisphere, the degree of blockage, and the availability of collateral circulation." Explanation: 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.) Clinical manifestations of a stroke do not depend on the cardiovascular health of the client or how quickly the clot can be dissolved. Clinical manifestations of a stroke are not "general" but individual.
A nurse in a rehabilitation facility is coordinating the discharge of a client who is tetraplegic. The client, who is married and has two children in high school, is being discharged to home and will require much assistance. Who would the discharge planner recognize as being the most important member of this client's care team? home care nurse physical therapist spouse chaplain
spouse Explanation: The client's spouse and family would need to be involved in the everyday care of the client; without their support, it is unlikely that the client would be able to manage at home.
A client has a 12-year history of cluster headaches. After the client describes the characteristics of the head pain, the nurse begins to discuss its potential causes. What would the nurse indicate that the origin of the headaches is: muscular. endocrine. unknown. vasodilating agents.
unknown. Explanation: Although cluster headaches can be triggered by vasodilating agents, the cause of cluster headaches is unknown.
When communicating with a client who has sensory (receptive) aphasia, the nurse should: speak loudly and articulate clearly. give the client a writing pad. use short, simple sentences. allow time for the client to respond.
use short, simple sentences. Explanation: Although sensory aphasia allows the client to hear words, it impairs the ability to comprehend their meaning. The nurse should use short, simple sentences to promote comprehension. Allowing time for the client to respond might be helpful but is less important than simplifying the communication. Because the client's hearing isn't affected, speaking loudly isn't necessary. A writing pad is helpful for clients with expressive, not receptive, aphasia.
A 154-pound woman has been prescribed tPA (0.9 mg/kg) for an ischemic stroke. The nurse knows to give how many mg initially? 10 mg 6.3 mg 8.3 mg 7.5 mg
6.3 mg Explanation: A person who weighs 154 lbs weighs 70 kg. To calculate total dosage, multiply 70 × 0.9 mg/kg = 63 mg. Ten percent of the calculated dose is given as an IV bolus over 1 minute. The remaining dose (90%) is given IV over 1 hour via an infusion pump. So initially the nurse gives 10% (6.3 mg) over 1 minute.
Which term refers to the failure to recognize familiar objects perceived by the senses? Agraphia Agnosia Apraxia Perseveration
Agnosia Explanation: Auditory agnosia is failure to recognize significance of sounds. Agraphia refers to disturbances in writing intelligible words. Apraxia refers to an inability to perform previously learned purposeful motor acts on a voluntary basis. Perseveration is the continued and automatic repetition of an activity, word, or phrase that is no longer appropriate.
The provider diagnoses the patient as having had an ischemic stroke. The etiology of an ischemic stroke would include which of the following? Cerebral aneurysm Arteriovenous malformation Cardiogenic emboli Intracerebral hemorrhage
Cardiogenic emboli Explanation: Aneurysms, hemorrhages, and malformations are all examples of a hemorrhagic stroke. An embolism can block blood flow, leading to ischemia.
A 76-year-old 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? Stent placement Removal of the carotid artery Percutaneous transluminal coronary artery angioplasty Carotid endarterectomy
Carotid endarterectomy Explanation: If narrowing of the carotid artery by atherosclerotic plaques is the cause of the TIAs, a carotid endarterectomy (surgical removal of atherosclerotic plaque) is a treatment option. A balloon angioplasty, a procedure similar to a percutaneous transluminal coronary artery angioplasty, is performed to dilate the carotid artery and increase blood flow to the brain. Options A, B, and C are not surgical options to increase blood flow through the carotid artery to the brain.
A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to perform which action? Form words that are understandable Comprehend spoken words Form words that are understandable or comprehend spoken words Speak at all
Form words that are understandable or comprehend spoken words Explanation: Global aphasia is a combination of expressive and receptive aphasia and presents a tremendous challenge to the nurse to effectively communicate with the client. In receptive and expressive aphasia, the client is unable to form words that are understandable. The client who is unable to speak at all is referred to as mute.
From which direction should a nurse approach a client who is blind in the right eye? From directly behind the client From the right side of the client From directly in front of the client From the left side of the client
From the left side of the client Explanation: The nurse should approach the client from the left side so that the client can be aware of the nurse's approach. Likewise, personal items should be placed on the client's left side so that he can see them easily.
Which disturbance results in loss of half of the visual field? Anisocoria Diplopia Homonymous hemianopsia Nystagmus
Homonymous hemianopsia Explanation: Homonymous hemianopsia (loss of half of the visual field) may occur from stroke and may be temporary or permanent. Double vision is documented as diplopia. Nystagmus is ocular bobbing and may be seen in multiple sclerosis. Anisocoria is unequal pupils.
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? Visual and auditory agnosia Hemiplegia or hemiparesis Lack of deep tendon reflexes Limited attention span and forgetfulness
Limited attention span and forgetfulness Explanation: 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. Damage to the motor neurons may cause hemiparesis, hemiplegia, and a change in reflexes. Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia.
The nurse is caring for a client diagnosed with a hemorrhagic stroke. The nurse recognizes that which intervention is most important? Administering a stool softener Monitoring for seizure activity Maintaining a patent airway Elevating the head of the bed to 30 degrees
Maintaining a patent airway Explanation: 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 hemoglobin and hematocrit at acceptable levels will assist in maintaining tissue oxygenation. All other interventions are appropriate, but the airway takes priority. The head of the bed should be elevated to 30 degrees, monitoring the client because of the risk for seizures, and stool softeners are recommended to prevent constipation and straining, but these are not the most important interventions.
A nurse is planning care for a client who experienced a stroke in the right hemisphere of his brain. What should the nurse do? Anticipate the client will exhibit some degree of expressive or receptive aphasia. Provide close supervision because of the client's impulsiveness and poor judgment. Support the right arm with a sling or pillow to prevent subluxation. Place the wheelchair on the client's left side when transferring him into a wheelchair.
Provide close supervision because of the client's impulsiveness and poor judgment. Explanation: The primary symptoms of a client who experiences a right-sided stroke are left-sided weakness, impulsiveness, and poor judgment. Aphasia is more commonly present when the dominant or left hemisphere is damaged. When a client has one-sided weakness, the nurse should place the wheelchair on the client's unaffected side. Because a right-sided stroke causes left-sided paralysis, the right side of the body should remain unaffected.
While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are: Confusion or change in mental status Foot drop and external hip rotation Severe headache and early change in level of consciousness Weakness on one side of the body and difficulty with speech
Severe headache and early change in level of consciousness Explanation: The main presenting symptoms for ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body, confusion or change in mental status, and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Foot drop and external hip rotation can occur if a stroke victim is not turned or positioned correctly.
A 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? diplopia bruit TIA atherosclerotic plaque
bruit Explanation: 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."
