Chapter 38: Caring for Clients with Cerebrovascular Disorders

A family member brings the client to the clinic for a follow-up visit after a stroke. The family member asks the nurse what he can do to decrease his chance of having another stroke. What would be the nurse's best answer? "Have your heart checked regularly." "Stop smoking as soon as possible." "Take your prescribed medication to bring down your sodium levels." "Eat a nutritious diet."

"Stop smoking a soon as possible."

A physician orders therapy with tissue plasminogen activator for a client. The nurse alerts the physician to a potential problem when reviewing the client's chart and seeing that the client had major surgery within the last:

14 days

The pathophysiology of an ischemic stroke involves the ischemic cascade, which includes the following steps:1. Change in pH2. Blood flow decreases3. A switch to anaerobic respiration <wbr />4. Membrane pumps fail5. Cells cease to function6. Lactic acid is generatedPut these steps in order in which they occur. 635241 352416 236145 162534

236145

A patient is admitted via ambulance to the emergency room of a stroke center at 1:30 p.m. with symptoms that the patient said began at 1:00 p.m. Within 1 hour, an ischemic stroke had been confirmed and the doctor ordered tPA. The nurse knows to give this drug no later than what time? 2:00 p.m. 3:00 p.m. 4:00 p.m. 7:00 p.m.

4:00 p.m.

A patient had a carotid endarterectomy yesterday and when the nurse arrived in the room to perform an assessment, the patient states, "All of a sudden, I am having trouble moving my right side." What concern should the nurse have about this complaint? A thrombus formation at the site of the endarterectomy This is a normal occurrence after an endarterectomy and would not be a concern. Bleeding from the endarterectomy site Surgical wound infection

A thrombus formation at the site of the endarterctomy

A nurse is teaching a community group about modifiable and nonmodifiable risk factors for ischemic strokes. Which of the following is a risk factor that cannot be modified? Hypertension Atrial fibrillation Advanced age Obesity

Advanced age

A clinic nurse is caring for a client diagnosed with migraine headaches. During the client teaching session, the client questions the nurse regarding alcohol consumption. What would the nurse be correct in telling the client about the effects of alcohol? Alcohol causes hormone fluctuations. Alcohol causes vasodilation of the blood vessels. Alcohol has an excitatory effect on the CNS. Alcohol diminishes endorphins in the brain.

Alcohol causes vasodilation of the blood vessels.

The nurse is taking care of a client with a headache. In addition to administering medications, the nurse takes which measure to assist the client in reducing the pain associated with the headache? Apply warm or cool cloths to the forehead or back of the neck. Maintain hydration by drinking eight glasses of fluid a day. Perform the Heimlich maneuver. Use pressure-relieving pads or a similar type of mattress.

Apply warm or cool cloths to the forehead or back of the neck.

If warfarin is contraindicated as a treatment for stroke, which medication is the best option? Dipyridamole Aspirin Clopidogrel Ticlodipine

Aspirin

The nurse is reviewing the medication administration record of a female client who possesses numerous risk factors for stroke. Which of the woman's medications carries the greatest potential for reducing her risk of stroke? Naproxen 250 PO b.i.d. Calcium carbonate 1,000 mg PO b.i.d. Aspirin 81 mg PO o.d. Lorazepam 1 mg SL b.i.d. PRN

Aspirin 81 mg PO o.d.

A client with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the client's cardiac and neurologic status, the nurse monitors the client for signs of what complication? Acute pain Septicemia Bleeding Seizures

Bleeding

A patient diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse? Implement distraction techniques. Administer an analgesic. Inform the nurse-manager. Call the health care provider immediately.

Call the health care provider immediately.

A patient who has had a previous stroke and is taking warfarin tells the nurse that he started taking garlic to help reduce his blood pressure. The nurse knows that garlic when taken together with warfarin will produce which type of interaction? No drug to drug interactions, may be taken together Can greatly increase the international normalization ratio (INR), increasing the risk of bleeding Can cause platelet aggregation, increasing the risk of blood clotting May increase cerebral blood flow, causing migraine headaches

Can greatly increase the international normalization ratio (INR), increasing the risk of bleeding

A nurse is reading a journal article about stroke and the underlying causes associated with this condition. The nurse demonstrates understanding of the information when identifying which subtype of stroke as being due to atrial fibrillation? large-artery thrombotic small, penetrating artery thrombotic cardio embolic cryptogenic

Cardio embolic

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 Cerebral aneurysm Cardiogenic emboli Small artery thrombosis

Cerebral aneurysm

A community health nurse is conducting a workshop for unlicensed care providers who work in a chain of long-term care facilities. The nurse is teaching the participants about the signs and symptoms of stroke. What signs and symptoms should the nurse identify? Select all that apply. Epistaxis (nosebleed) Confusion Sudden numbness Sudden ear pain Visual disturbances

Confusion Sudden numbness Visual disturbances

The nurse is discharging home a client who had a stroke. The client has a flaccid right arm and leg and is experiencing urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common client response to a change in body image? Confusion Uncertainty Depression Disassociation

Depression

A nursing student is writing a care plan for a newly admitted client who has been diagnosed with a stroke. What major nursing diagnosis should most likely be included in the client's plan of care? Adult failure to thrive Post-trauma syndrome Hyperthermia Disturbed sensory perception

Disturbed sensory perception

A client is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this client is aware that an absolute contraindication for thrombolytic therapy is what? Evidence of hemorrhagic stroke Blood pressure of ≥ 180/110 mm Hg Evidence of stroke evolution Previous thrombolytic therapy within the past 12 months

Evidence of hemorrhagic stroke

A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to perform which action? Comprehend spoken words Form words that are understandable Form words that are understandable or comprehend spoken words Speak at all

Form words that are understandable or comprehend spoken words

From which direction should a nurse approach a client who is blind in the right eye? From directly in front of the client From the right side of the client From the left side of the client From directly behind the client

From the left side of the client

A stroke victim is experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe? Frontal Occipital Parietal Temporal

Frontal

When preparing to discharge a client home, the nurse has met with the family and warned them that the client may exhibit unexpected emotional responses. The nurse should teach the family that these responses are typically a result of what cause? Frustration around changes in function and communication Unmet physiologic needs Changes in brain activity during sleep and wakefulness Temporary changes in metabolism

Frustration around changes in function and communication

Which is a nonmodifiable risk factor for ischemic stroke? Atrial fibrillation Gender Hyperlipidemia Smoking

Gender

A client who had a cerebrovascular accident has dysphagia related to hemiplegia and has a history of aspiration. Which nursing interventions would be contraindicated for this client? Have the client tilt their head back to facilitate swallowing. Place thickened liquids or pureed food on the unaffected side of the mouth. Encourage the client to swallow several times. Offer or remind the client to load the fork or spoon with small amount of food.

Have the client tilt their head back to facilitate swallowing.

A client is experiencing dysphagia following a stroke. Which measure may be taken by the nurse to ensure that the client's diet allows for easy swallowing? Instruct the client to lie on the bed when eating. Offer liquids frequently and in large quantities. Help the client sit upright when eating and feed slowly. Allow optimum physical activity before meals to expedite digestion.

Help the client sit upright when eating and feed slowly.

An emergency department (ED) nurse has administered an ordered bolus of tissue plasminogen activator (tPA) to a male patient who was diagnosed with stroke. During the administration of tPA, the nurse should prioritize assessments related to what problem? Fluid overload Peripheral edema Hemorrhage Acute pain

Hemorrhage

A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? Heparin sodium Dexamethasone Methyldopa Phenytoin

Heparin sodium

A client diagnosed with a hemorrhagic stroke has been admitted to the neurologic ICU. The nurse knows that teaching for the client and family needs to begin as soon as the client is settled on the unit and will continue until the client is discharged. What will family education need to include? How to differentiate between hemorrhagic and ischemic stroke Risk factors for ischemic stroke How to correctly modify the home environment Techniques for adjusting the client's medication dosages at home

How to correctly modify the home environment

The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regimen, to maintain a healthy weight, and to adopt a reasonable exercise program. This advice is based on research data that shows the most important risk factor for stroke is: Obesity Dyslipidemia Smoking Hypertension

Hypertension

What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke? Left visual field deficit Aphasia Slow, cautious behavior Altered intellectual ability

Left visual field deficit

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? Diphenhydramine (Benadryl) Lioresal (Baclofen) Heparin Pregabalin (Lyrica)

Lioresal (Baclofen)

A nurse is caring for a client diagnosed with a hemorrhagic stroke. When creating this client's plan of care, what goal should be prioritized? Prevent complications of immobility. Maintain and improve cerebral tissue perfusion. Relieve anxiety and pain. Relieve sensory deprivation.

Maintain and improve cerebral tissue perfusion

A client is suspected of having had a stroke. Which is the initial diagnostic test for a stroke? Carotid Doppler Electrocardiography Transcranial Doppler studies Noncontrast computed tomography

Noncontrast computed tomography

A client has had an ischemic stroke and has been admitted to the medical unit. What action should the nurse perform to best prevent joint deformities? Place the client in the prone position for 30 minutes/day. Assist the client in acutely flexing the thigh to promote movement. Place a pillow in the axilla when there is limited external rotation. Place the client's hand in pronation.

Place a pillow in the axilla when there is external rotation

The nurse is caring for a client with dysphagia. Which intervention would be contraindicated while caring for this client? Assisting the client with meals Placing food on the affected side of the mouth Testing the gag reflex before offering food or fluids Allowing ample time to eat

Placing the food in the affected side of the mouth

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. 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. Support the right arm with a sling or pillow to prevent subluxation.

Provide close supervision because of the client's impulsiveness and poor judgement

As a member of the stroke team, the nurse knows that thrombolytic therapy carries the potential for benefit and for harm. The nurse should be cognizant of what contraindications for thrombolytic therapy? Select all that apply. INR above 1.0 Recent intracranial pathology Sudden symptom onset Current anticoagulation therapy Symptom onset greater than 3 hours prior to admission

Recent intracranial pathology Current anticoagulation therapy Symptom onset greater than 3 hours prior to admission

A client with CVA is prescribed medication to treat the disorder. The client wants to know what other measures may help reduce CVA. Which is an accurate suggestion for the client? Increase body weight moderately Reduce hypertension and high blood cholesterol Increase intake of proteins and carbohydrates Increase hydration and the intake of fluids

Reduce hypertension and high blood cholesterol

A nurse in the ICU is providing care for a client who has been admitted with a hemorrhagic stroke. The nurse is performing frequent neurologic assessments and observes that the client is becoming progressively more drowsy over the course of the day. What is the nurse's best response to this assessment finding? Report this finding to the health care provider as an indication of decreased metabolism. Provide more stimulation to the client and monitor the client closely. Recognize this as the expected clinical course of a hemorrhagic stroke. Report this to the health care provider as a possible sign of clinical deterioration.

Report this to the health care provider as a possible sign of clinical deterioration

The nurse practitioner is able to correlate a patient's neurologic deficits with the location in the brain affected by ischemia or hemorrhage. For a patient with a left hemispheric stroke, the nurse would expect to see: Spatial-perceptual deficits. Left visual field deficit. Right-sided paralysis. Impulsive behavior.

Right-sided paralysis

The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient? High-Fowler's Prone Supine Semi-Fowler's

Semi-Fowler's

A patient is exhibiting classic signs of a hemorrhagic stroke. What complaint from the patient would be an indicator of this type of stroke? Numbness of an arm or leg Double vision Severe headache Dizziness and tinnitus

Severe headache

Which is a modifiable risk factor for transient ischemic attacks and ischemic strokes? Thyroid disease Social drinking Advanced age Smoking

Smoking

The nurse is preparing health education for a client who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in this education? Mild, intermittent seizures can be expected. Take ibuprofen for complaints of a serious headache. Take antihypertensive medication as prescribed. Drowsiness is normal for the first week after discharge.

Take antihypertensive medication as prescribed

A client reports frequent headaches and is seeing the physician to determine their cause. In client education, which type of headache does the nurse indicate is most common? tension migraine cluster secondary

Tension

A client who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurse's care of this client? The client should be approached on the side where visual perception is intact. Attention to the affected side should be minimized in order to decrease anxiety. The client should avoid turning in the direction of the defective visual field to minimize shoulder subluxation. The client should be approached on the opposite side of where the visual perception is intact to promote recovery.

The client should be approached on the side where visual perception is intact

A client recovering from a stroke has severe shoulder pain from subluxation of the shoulder. To prevent further injury and pain, the nurse caring for this client is aware of what principle of care? The client should be fitted with a cast because use of a sling should be avoided due to adduction of the affected shoulder. Elevation of the arm and hand can lead to further complications associated with edema. Passively exercising the affected extremity is avoided in order to minimize pain. The client should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder.

The client should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder.

A client who has experienced an ischemic stroke has been admitted to the medical unit. The client's family is adamant that she remain on bed rest to hasten her recovery and to conserve energy. What principle of care should inform the nurse's response to the family? The client should mobilize as soon as she is physically able. To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks. The client should remain on bed rest until she expresses a desire to mobilize. Lack of mobility will greatly increase the client's risk of stroke recurrence.

The client should mobilize as soon as she is physically able.

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 After the nurse has received the discharge orders The day the patient has the stroke

The day the patient has the stroke

An emergency department nurse is awaiting the arrival of a client with signs of an ischemic stroke that began 1 hour ago, as reported by emergency medical personnel. The treatment window for thrombolytic therapy is which of the following? Three hours One hour Two hours Six hours

Three hours

A client diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for what purpose? To decrease cerebral edema To prevent seizure activity that is common following a TIA To remove atherosclerotic plaques blocking cerebral flow To determine the cause of the TIA

To removed atherosclerotic plaque blocking cerebral flow

The nurse is providing nonpharmacologic interventions for pain relief to a client with a tension headache. Which techniques may the nurse use? Select all that apply. Use guided imagery. Play soothing music. Allow interactions with friends and family members. Allow watching TV.

Use guided imagery. Play soothing music.

When communicating with a client who has sensory (receptive) aphasia, the nurse should: allow time for the client to respond. speak loudly and articulate clearly. give the client a writing pad. use short, simple sentences.

Use short simple sentences

A client has a 12-year history of migraine headaches and is frustrated over how these headaches impact lifestyle. What would the nurse indicate to the client is the origin of migraines? vascular muscular light endocrine

Vascular

The nurse is performing stroke risk screenings at a hospital open house. The nurse has identified four clients who might be at risk for a stroke. Which client is likely at the highest risk for a hemorrhagic stroke? White female, age 60, with history of excessive alcohol intake White male, age 60, with history of uncontrolled hypertension Black male, age 60, with history of diabetes Black male, age 50, with history of smoking

White male, age 60, with history of uncontrolled hypertension

A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the health care provider in the emergency department. Which is the origin of the client's symptoms? impaired cerebral circulation cardiac disease diabetes insipidus hypertension

impaired cerebral circulation

A client has suffered several migraines per month for the last 4 months. The physician prescribes prophylactic drug therapy. What is the rationale behind this action? Select all that apply. possible reduction in frequency of attacks possible reduction of migraine intensity possible reduction in migraine duration prevention of all migraines

possible reduction in frequency of attacks possible reduction of migraine intensity possible reduction in migraine duration

The nurse is providing diet-related advice to a client who experienced a cerebrovascular accident (CVA). The client wants to minimize his volume of food and yet meet all nutritional requirements. To control the volume of food intake, the nurse should suggest that the client consume: thickened commercial beverages and fortified cooked cereals. dry or crisp foods and chewy meats. hot or tepid foods. a high-fat diet.

thickened commercial beverages and fortified cooked cereals