Med Surg Chapter Forty Five

2, 4, 5

An hour later after a CT scan, the patient is diagnosed with a left hemisphere stroke. Which manifestations would you expect? (Select all that apply) 1. Disorientation to time, place, and person 2. Inability to discriminate words and letters 3. Constant smiling 4. Intellectual impairment 5. Neglect of left visual field 6. Deficits in the right visual field

2, 4, 5

The nurse is caring for a client who is at risk for increased intracranial pressure (ICP) after a stroke. Which activities performed by the nurse will assist with preventing increases in ICP? Select all that apply. 1. Clustering nursing activités 2. Hyperoxygenating before suctioning 3. Maintaining 20 degree flexion of the knees 4. Maintaining the head and neck in midline position 5. Maintaining the head of the bed at 30 degrees elevation

1, 4, 5

The nurse is caring for a client with an intracranial aneurysm who was previously alert. Which sign is an early indication that the level of consciousness (LOC) is deteriorating? Select all that apply. 1. mild drowsiness 2. drooping eyelids 3. ptosis of the left eyelid 4. sight slurring of speech 5. less frequent spontaneous speech

c

The spouse of a patient brought to the ED states that 6 hours ago her husband began having difficulty finding words. The patient has since become progressively worse. He has right hemiparesis. Upon assessing the patient, you note that he is lying flat in a supine position and has been incontinent of urine. What is the priority nursing intervention for this patient at this time? 1. Provide perineal care 2. Assess for gag reflex 3. Elevate the head of bed 4. Perform a linen and gown change

2

What is the greatest risk for a patient with dysfunction of cranial nerves IX and X? 1. Dehydration 2. Aspiration pneumonia 3. Constipation 4. Weight loss

c

What percent of strokes occur in patients less than 65 years of age? A. 10% B. 15% C. 25% D. 35%

c

Which symptom is the earliest indicator of increased intracranial pressure? A. Increased pupil size B. Elevated blood pressure C. Agitation and confusion D. Nausea and vomiting