Stroke4

2. pupil size and pupillary response

16. What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? 1. cholesterol level 2. pupil size and pupillary response 3. bowel sounds 4. echocardiogram

1. headache reduced 4. responds to comfort measures 5. no signs or symptoms of bleeding

39. Which outcomes indicate effective management of a conscious client who is being treated with recombinant tissue plasminogen therapy during the initial phase of an ischemic cerebral vascular accident (CVA)? Select all that apply. 1. headache reduced 2. dysphagia improved 3. visual disturbances improved 4. responds to comfort measures 5. no signs or symptoms of bleeding

3. Offer solid foods from the unaffected side of the mouth.

40. Following a stroke, a client has dysphagia and left-sided facial paralysis. Which feeding technique will be most helpful at this time? 1. Encourage sipping diluted liquid meal supplements from a straw. 2. Position the client with the bed at a 30-degree angle. 3. Offer solid foods from the unaffected side of the mouth. 4. Feed the client a soft diet from a spoon into the left side of the mouth.

15 points

41. A client is being monitored for transient ischemic attacks. The client is oriented, can open the eyes spontaneously, and follows commands. What is the Glasgow Coma Scale score?

2. "Maximum dosage is not achieved until 3 to 4 days after starting the medication." 3. "Effects of the drug continue for 4 to 5 days after discontinuing the medication." 5. "I should have my blood levels tested periodically."

42. The nurse is teaching a client about taking prophylactic warfarin sodium. Which statement indicates that the client understands how to take the drug? Select all that apply. 1. "The drug's action peaks in 2 hours." 2. "Maximum dosage is not achieved until 3 to 4 days after starting the medication." 3. "Effects of the drug continue for 4 to 5 days after discontinuing the medication." 4. "Protamine sulfate is the antidote for warfarin." 5. "I should have my blood levels tested periodically."

1. placing the client on the back with a small pillow under the head

43. Which action is not appropriate when providing oral hygiene for a client who has had a strøke? 1. placing the client on the back with a small pillow under the head 2. keeping portable suctioning equipment at the bedside 3. opening the client's mouth with a padded tongue blade 4. cleaning the client's mouth and teeth with a toothbrush

3. identify the time of onset of the stroke.

44. A client arrives in the emergency department with an ischemic stroke. Because the healthcare team is considering administering tissue plasminogen activator (t-PA) administration, the nurse should first: 1. ask what medications the client is taking. 2. complete a history and health assessment. 3. identify the time of onset of the stroke. 4. determine if the client is scheduled for any surgical procedures.

3. blood pressure.

45. During the first 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal is to control the client's: 1. pulse. 2. respirations. 3. blood pressure. 4. temperature.

4. Provide sedation. 2. Hyperoxygenate 1. Suction the airway 3. Suction the mouth

47. A client with a hemorrhagic stroke is slightly agitated, heart rate is 118 bpm, respirations are 22 breaths/min, bilateral rhonchi are auscultated, SpO2 is 94%, blood pressure is 144/88 mm Hg, and oral secretions are noted. What order of interventions from first to last should the nurse follow when suctioning the client to prevent increased intracranial pressure (ICP) and maintain adequate cerebral perfusion? All options must be used. 1. Suction the airway. 2. Hyperoxygenate. 3. Suction the mouth. 4. Provide sedation.

1. the rehabilitation plan will be guided by it.

48. In planning care for the client who has had a stroke, the nurse should obtain a history of the client's functional status before the stroke because: 1. the rehabilitation plan will be guided by it. 2. functional status before the stroke will help predict outcomes. 3. it will help the client recognize physical limitations. 4. the client can be expected to regain most functional status.

2. sliding the client to move up in bed

49. Which positioning technique is not appropriate when the nurse changes a client's position in bed if the client has hemiparalysis? 1. rolling the client onto the side 2. sliding the client to move up in bed 3. lifting the client when moving the client up in bed 4. having the client help lift off the bed using a trapeze

3. Have the client wear ankle-high tennis shoes at intervals throughout the day.

51. Which is the most effective means of preventing plantar flexion in a client who has had a stroke with residual paralysis? 1. Place the client's feet against a firm footboard. 2. Reposition the client every 2 hours. 3. Have the client wear ankle-high tennis shoes at intervals throughout the day. 4. Massage the client's feet and ankles regularly.

1. placing a pillow in the axilla so the arm is away from the body 2. Inserting a pillow under the slightly flexed arm so the hand is higher than the elbow 4. Positioning a hand cone in the hand so the fingers are barely flexed

52. The nurse is planning the care of a hemiplegic client to prevent joint deformities of the arm and hand. Which position is appropriate? Select all that apply. 1. placing a pillow in the axilla so the arm is away from the body 2. inserting a pillow under the slightly flexed arm so the hand is higher than the elbow 3. immobilizing the extremity in a sling 4. positioning a hand cone in the hand so the fingers are barely flexed 5. keeping the arm at the side using a pillow

2. using a "picture board" for the client to point to pictures

53. For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication? 1. speaking loudly and slowly 2. using a "picture board" for the client to point to pictures 3. writing directions so the client can read them 4. speaking in short sentences

1. maintaining an upright position while eating 3. introducing foods on the unaffected side of the mouth 4. keeping distractions to a minimum

54. The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which strategies should the nurse include in the teaching plan? Select all that apply. 1. maintaining an upright position while eating 2. restricting the diet to liquids until swallowing improves 3. introducing foods on the unaffected side of the mouth 4. keeping distractions to a minimum 5. cutting food into large pieces of finger food

4. Turn the head from side to side when walking.

56. A nurse is teaching a client who had a stroke about ways to adapt to a visual disability. Which does the nurse identify as the primary safety precaution to use? 1. Wear a patch over one eye. 2. Place personal items on the sighted side. 3. Lie in bed with the unaffected side toward the door. 4. Turn the head from side to side when walking.

3. Attempt to divert the client's attention.

57. A client is experiencing mood swings after a stroke and often has episodes of tearfulness that are distressing to the family. Which is the best technique for the nurse to instruct family members to try when the client experiences a crying episode? 1. Sit quietly with the client until the episode is over. 2. Ignore the behavior. 3. Attempt to divert the client's attention. 4. Tell the client that this behavior is unacceptable.

1. Present one thought at a time. 3. Speak with normal volume. 4. Make use of gestures. 5. Encourage pointing to the needed object.

58. When communicating with a client who has aphasia, which approaches are helpful? Select all that apply. 1. Present one thought at a time. 2. Avoid writing messages. 3. Speak with normal volume. 4. Make use of gestures. 5. Encourage pointing to the needed object.

3. dissolved emboli

59. What is the expected outcome of thrombolytic drug therapy for stroke? 1. increased vascular permeability 2. vasoconstriction 3. dissolved emboli 4. prevention of hemorrhage