Chapter 62 PrepU

As many as 84% of patients with stroke suffer severe shoulder pain which may prevent them from achieving balance and performing transfers and self-care activities. T/F

TRUE

Hypertension is the most common cause of intracerebral hemorrhage. T/F

TRUE

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?

6.3 mg

How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tPA)?

15 minutes

A client undergoes cerebral angiography for evaluation of a subarachnoid hemorrhage. Which findings indicate spasm or occlusion of a cerebral vessel by a clot?

Hemiplegia, seizures, and decreased level of consciousness

is the most common cause of intracerebral hemorrhage.

hypertension

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 depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation."

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?

Advanced age

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

Heparin sodium

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.

The nurse is caring for a client with a history of transient ischemic attacks (TIAs) and moderate carotid stenosis who has undergone a carotid endarterectomy. Which postoperative finding would cause the nurse the most concern?

Difficulty swallowing

Disturbances in the left visual field and spatial-perceptual deficits are most frequently seen in patients with left hemispheric damage. T/F

FALSE

The goal for thrombolytic therapy for patients with ischemic stroke is to administer IV t-PA within 2 hours of the patient arriving to the ER. T/F

FALSE

A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to do perform which action?

Form understandable words and comprehend spoken words

From which direction should a nurse approach a client who is blind in the right eye?

From the left side of the client

An _____________ stroke, cerebrovascular disease, or "brain attack" is described as a sudden loss of function resulting from disruption of the blood supply to a part of the brain.

ISCHEMIC

Which is a contraindication for the administration of tissue plasminogen activator (t-PA)?

Intracranial hemorrhage

Which are contraindications for the administration of tissue plasminogen activator (t-PA)? Select all that apply.

Intracranial hemorrhage Major abdominal surgery within 10 days

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?

Left-sided cerebrovascular accident (CVA)

Which of the following is accurate regarding a hemorrhagic stroke?

Main presenting symptom is an "exploding headache."

Which clinical manifestation would be exhibited by a client following a hemorrhagic stroke of the right hemisphere?

Neglect of the left side

The nurse is caring for a client with dysphagia. Which intervention would be contraindicated while caring for this client?

Placing food on the affected side of the mouth

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?

Remove throw rugs and electrical cords from home environment.

Which is a modifiable risk factor for transient ischemic attacks and ischemic strokes?

Smoking

An intracranial aneurysm is a dilation of the walls of a cerebral artery that develops as a result of weakness in the arterial wall. T/F

TRUE

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

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?

Transient ischemic attack

The main surgical procedure for selected patients with TIAs and mild stroke is ___________________.

carotid endarterectomy

Hemorrhagic strokes are primarily caused by __________ hemorrhage or subarachnoid hemorrhage.

intracranial

Cerebral _____________ is a serious complication of subarachnoid hemorrhage and is a leading cause of morbidity and mortality in those who survive the initial hemorrhage.

vasospasm