ML Quiz Ch 67

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?

4:00 pm

A client has experienced an ischemic stroke that has damaged the temporal (lateral and superior portions) lobe. Which of the following deficits would the nurse expect during assessment of this client? A. Auditory agnosia B. Limited attention span and forgetfulness C. Lack of deep tendon reflexes D. Hemiplegia or hemiparesis

A

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? A. Left-sided cerebrovascular accident (CVA) B. Transient ischemic attack (TIA) C. Completed Stroke D. Right-sided cerebrovascular accident (CVA)

A

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? A. Diastolic pressure of 110 mm Hg B. Heart rate of 100 C. Respiration of 22 D. Systolic pressure of 130 mm Hg

A

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

C

A client has experienced an ischemic stroke that has damaged the lower motor neurons of the brain. Which of the following deficits would the nurse expect during assessment? A. Visual agnosia B. Limited attention span and forgetfulness C. Auditory agnosia D. Lack of deep tendon reflexes

D

A client reports light-headedness, speech disturbance, and left-sided weakness lasting for several hours. The neurologist diagnosed a transient ischemic attack, which caused the client great concern. What would the nurse include during client education? A. A TIA is an insidious, often chronic episode of neurologic impairment. B. Two thirds of people that experience a TIA will go on to develop a stroke. C. Symptoms of a TIA may linger for up to a week. D. When symptoms cease, the client will return to presymptomatic state.

D

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention? A. Maintaining the client in a quiet environment B. Positioning the client to prevent airway obstruction C. Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess D. Keeping the client in one position to decrease bleeding

D

Which term refers to the failure to recognize familiar objects perceived by the senses? A. Agnosia B. Perseveration C. Apraxia D. Agraphia

A

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? A. chaplain B. home care nurse C. spouse D. physical therapist

C

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

C

During assessment of cognitive impairment, post-stroke, the nurse documents that the patient was experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe? A. Parietal B. Temporal C. Occipital D. Frontal

D

Which term will the nurse use when referring to blindness in the right or left half of the visual field in both eyes? A. Homonymous hemianopsia B. Nystagmus C. Scotoma D. Diplopia

A

A nurse knows that, for a patient with an ischemic stroke, tPA is contraindicated if the blood pressure reading is: A. 185 mm Hg/110 mm Hg B. 175 mm Hg/100 mm Hg C. 190 mm Hg/120 mm Hg D. 170 mm Hg/105 mm Hg

C

Which is a contraindication for the administration of tissue plasminogen activator (t-PA)? A. Ischemic stroke B. Age 18 years or older C. Intracranial hemorrhage D. Systolic blood pressure less than or equal to 185 mm Hg

C

The nurse is participating in a health fair for stroke prevention. Which will the nurse say is a modifiable risk factor for ischemic stroke? A. Social drinking B. Thyroid disease C. Advanced age D. Smoking

D

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

A

A client is receiving an IV infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant? A. Increased urine output B. Elevated blood pressure C. Decreased level of consciousness (LOC) D. Decreased heart rate

A

A client on your unit is scheduled to have intracranial surgery in the morning. Which nursing intervention helps to avoid intraoperative complications, reduce cerebral edema, and prevent postoperative vomiting? A. Restrict fluids before surgery. B. Administer preoperative sedation. C. Administer prescribed medications. D. Administer an osmotic diuretic.

A

A client with a history of atrial fibrillation has experienced a TIA. In an effort to reduce the risk of cerebrovascular accident (CVA), the nurse anticipates the priority medical treatment to include which of the following? A. Anticoagulant therapy B. Carotid endarterectomy C. Cholesterol-lowering drugs D. Monthly prothrombin levels

A

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. A thrombus formation at the site of the endarterectomy B. This is a normal occurrence after an endarterectomy and would not be a concern. C. Bleeding from the endarterectomy site D. Surgical wound infection

A

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: A. Hypertension B. Smoking C. Obesity D. Dyslipidemia

A

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? A. 8.3 mg B. 6.3 mg C. 7.5 mg D. 10 mg

B

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? A. A ruptured arteriovenous malformation will cause deficits until it is stopped. B. Thrombolytic therapy has a time window of only 3 hours. C. Intracranial pressure is increased by a space-occupying bleed. D. A ruptured intracranial aneurysm must quickly be repaired.

B

A patient is brought to the emergency department with a possible stroke. What initial diagnostic test for a stroke, usually performed in the emergency department, would the nurse prepare the patient for? A. Transcranial Doppler flow study B. Noncontrast computed tomogram C. 12-lead electrocardiogram D. Carotid ultrasound study

B

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

C

The nurse is caring for a client following an aneurysm coiling procedure. The nurse documents that the client is experiencing Korsakoff syndrome. Which set of symptoms characterizes Korsakoff syndrome? A. Choreiform movement and dementia B. Tremor, rigidity, and bradykinesia C. Psychosis, disorientation, delirium, insomnia, and hallucinations D. Severe dementia and myoclonus

C

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

C

Which is the most common motor dysfunction seen in clients diagnosed with stroke? A. Hemiparesis B. Ataxia C. Hemiplegia D. Diplopia

C

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? A. "This behavior is common in clients with stroke. Which does your spouse do more often? Laugh or cry?" B. "You sound stressed; maybe using some stress management techniques will help." C. "You seem upset, and it may be hard for you to focus on the teaching, I'll come back later." D. "Emotional lability is common after a stroke, and it usually improves with time."

D

When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke? A. The day before the patient is discharged B. After the nurse has received the discharge orders C. After the patient has passed the acute phase of the stroke D. The day the patient has the stroke

D

Which of the following antiseizure medication has been found to be effective for post-stroke pain? A. Phenytoin (Dilantin) B. Topiramate (Topamax) C. Carbamazepine (Tegretol) D. Lamotrigine (Lamictal)

D

Which are contraindications for the administration of tissue plasminogen activator (t-PA)? Select all that apply. A. Ischemic stroke B. Systolic BP less than or equal to 185 mm Hg C. Age 18 years or older D. Major abdominal surgery within 10 days E. Intracranial hemorrhage

D, E

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? A. Pregabalin (Lyrica) B. Lioresal (Baclofen) C. Diphenhydramine (Benadryl) D. Heparin

B

Which clinical manifestation would be exhibited by a client following a hemorrhagic stroke of the right hemisphere? A. Expressive aphasia B. Neglect of the left side C. Inability to move the right arm D. Neglect of the right side

B

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

C

A nurse is assisting with a community screening for people at high risk for stroke. To which of the following clients would the nurse pay most attention? A. A 28-year-old pregnant African-American woman B. A 40-year-old Caucasian woman C. A 62-year-old Caucasian woman D. A 60-year-old African-American man

D

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 bestalternative medication to give is A. ticlopidine. B. clopidogrel. C. aspirin. D. dipyridamole.

C

The nurse is caring for a client diagnosed with a hemorrhagic stroke. The nurse recognizes that which intervention is most important? A. Elevating the head of the bed to 30 degrees B. Administering a stool softener C. Maintaining a patent airway D. Monitoring for seizure activity

C

A client undergoes cerebral angiography for evaluation of a subarachnoid hemorrhage. Which findings indicate spasm or occlusion of a cerebral vessel by a clot? A. Tachycardia, tachypnea, and hypotension B. Difficulty breathing or swallowing C. Hemiplegia, seizures, and decreased level of consciousness D. Nausea, vomiting, and profuse sweating

C

A client's spouse relates how the client reported a severe headache and then was unable to talk or move their right arm and leg. After diagnostics are completed and the client is admitted to the hospital, when would basic rehabilitation begin? A. after 1 week B. upon transfer to a rehabilitation unit C. immediately D. in 2 to 3 days

C

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

C

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? A. Two hours B. Six hours C. Three hours D. One hour

C