MS2 Chap 49
A patient tells the nurse that at times it seems like the mouth muscles do not want to work and the patients speech is slurred. What should the nurse realize that the patient is describing? a. Diplopia b. Dysarthria c. Dysphagia d. Dysrhythmia
b
A patient comes into the emergency department with symptoms of a stroke. Which medication should the nurse expect may be given to the patient if diagnostic testing confirms an ischemic stroke? a. Heparin b. Clopidogrel (Plavix) c. Warfarin (Coumadin) d. Tissue-type plasminogen activator (tPA)
d
The nurse is planning information about stroke frequency as part of a community health education program. Which demographic groups should the nurse include that are at higher than average risk for stroke? (Select all that apply.) a. Pregnant women b. Asian Americans c. American Indians d. African Americans e. Men and women 75 years old or older f. Individuals who have had a transient ischemic attack (TIA)
a, c, d, e, f
The nurse is assisting with a community education program about stroke prevention. Which are non-modifiable risk factors for stroke that the nurse should include? (Select all that apply.) a. Gender b. Obesity c. Diabetes d. Heredity e. Smoking f. Elevated blood lipids
a, d
A patient began experiencing manifestations of a stroke at 0800 hours. By which time should thrombolytic medications be provided to reverse stroke symptoms? a. 0900 hours b. 1250 hours c. 1400 hours d. 1660 hours
b
A patient is admitted to the hospital with a severe headache and photophobia. A lumbar puncture confirms a bleeding aneurysm. What nursing interventions should the nurse anticipate assisting with to prevent increased intracranial pressure (ICP) during the acute phase of illness? a. Morphine, dark glasses, and expectorants b. Quiet room, head of bed up, and stool softeners c. Coughing and deep breathing exercises and tranquilizers d. Range of motion exercises, bedside commode, and suctioning as needed
b
A patient is prescribed an antiplatelet agent to prevent strokes. Which agent was this patient most likely prescribed? a. Aspirin b. Warfarin (Coumadin) c. Acetaminophen (Tylenol) d. Tissue-type plasminogen activator (tPA)
a
A patient with symptoms of impending stroke is scheduled to have a cerebral angiogram. Which statement should the nurse include when assisting with patient teaching? a. This test is designed to detect vascular lesions in the brain. b. The angiogram is done to help identify swelling in the brain. c. We need to do this to evaluate electrical function of the brain. d. This test is done to examine cerebrospinal fluid for signs of bleeding.
a
The nurse is planning care for a patient with an intracerebral hemorrhage. What should be identified as a goal for this patient? a. Maintain blood pressure below 120/80 mm Hg b. Resume activities of daily living as soon as possible c. Expect to experience transient numbness and tingling d. Receive thrombolytic medication therapy within an hour
a
The nurse is assisting with a community education program related to cerebral vascular accidents. What should be included in a list of symptoms that need immediate medical attention? (Select all that apply.) a. Sudden trouble seeing in one or both eyes b. Sudden severe headache with no known cause c. Sudden confusion, trouble speaking, or understanding d. Sudden loss of hearing, ringing in the ears, or stabbing ear pain e. Sudden trouble walking, dizziness, or loss of balance or coordination f. Sudden numbness or weakness of face, arm, or leg, especially on one side of the body
a, b, c, e, f
The LPN has been asked to help a patient eat who has impaired swallowing due to a stroke. What should be included in the plan of care? (Select all that apply.) a. Have suction equipment available. b. Stay with the patient during meals. c. Encourage the patient to eat slowly. d. Offer the patient a straw for liquids. e. Instruct the patient to try to chew on both sides of the mouth. f. Place the patient in high Fowlers position or in a chair for meals.
a, b, c, f
A 56 year old female client asks why the nurse is assessing her for a stroke. Which manifestations did the nurse use to make this assessment decision? (Select all that apply.) a. Nausea b. Hiccups c. Itchy skin d. Chest pain e. Palpitations
a, b, d, e
A patient with a temporary loss of motor function is diagnosed with a transient ischemic attack (TIA). What should the nurse include when assisting in the teaching about this health problem? a. You had a small hemorrhage in your brain. b. Your brain was temporarily deprived of oxygen. c. The neurons in your brain are tangled, so messages get mixed up. d. You have a vessel that is occluded, blocking the blood supply to your brain.
b
The nurse is providing care for a patient with expressive aphasia. What should the nurse expect to find in the patients plan of care? (Select all that apply.) a. Speak loudly. b. Use a picture board. c. Obtain an interpreter. d. Provide pencil and paper. e. Speak slowly and clearly. f. Gesture or pantomime the message.
b, d
A patient enters the emergency department with right-sided weakness and vision changes. What assessment finding should be communicated to the registered nurse (RN) or HCP immediately? a. Blood glucose 150 mg/dL b. Blood pressure 148/92 mm Hg c. Onset of symptoms occurred 90 minutes ago d. History of transient ischemic attack (TIA) 3 months ago
c
A patient is diagnosed with a stroke that occurred at 12 noon the previous day. When should the nurse plan to begin bedside physical therapy with this patient? a. After 5 days b. Within 2 to 3 days c. By 12 noon on the current day d. At least one week after the occurrence
c
A patient with a cerebrovascular accident (stroke) has left-sided flaccidity and is unable to speak but seems to understand everything the nurse says. Which term should the nurse use to document the patients communication impairment? a. Sensory aphasia b. Motor dysphagia c. Expressive aphasia d. Receptive dysphagia
c
The nurse is caring for a hospitalized patient who has had a stroke and is waiting to be transferred to a rehabilitation facility. What nursing action can best maximize the patients rehabilitation potential while awaiting the transfer? a. Teach the patient what to expect at the rehabilitation facility. b. Keep the patient on bedrest to conserve energy for rehabilitation. c. Call the physical therapist for bedside rehabilitation until the transfer. d. Turn the patient every 2 hours to prevent pressure ulcers and contractures.
c
The nurse is documenting care provided to a patient with left-sided flaccidity caused by a stroke. Which term should the nurse use to document this patients motor status? a. Ipsilateral paraplegia b. Ipsilateral hemiparesis c. Contralateral hemiplegia d. Contralateral quadriparesis
c
The nurse is planning care for a client with right-sided weakness and aphasia from a transient ischemic attack (TIA). Which area of the brain should the nurse realize was affected in this client? a. Medulla b. Occipital lobe c. Left hemisphere d. Right hemisphere
c
The nurse is reviewing teaching provided to a patient with transient ischemic attack (TIA). Which statement indicates that further teaching is required? a. The risk factors and symptoms of a TIA are just like those of a stroke. b. I need to stop smoking to help lower my chances of this happening again. c. My risk for Alzheimers disease is increased now, so Ill have to stop driving. d. I recognize how important it is to take my anti-hypertension medications regularly.
c
The patient is diagnosed with a cerebral vascular accident that has the slowest rate of recovery and the highest probability of causing extensive neurological deficits. For which type of stroke should the nurse plan care for this patient? a. Thrombotic stroke b. Cerebral aneurysm c. Subarachnoid hemorrhage (SAH) d. Reversible ischemic neurological deficit (RIND)
c
he nurse is assisting in preparing a patient for transfer to a rehabilitation facility after a stroke. What should the nurse explain as the goal for rehabilitation? a. To monitor neurological status b. To cure any effects of the stroke c. To maximize remaining abilities d. To determine the extent of neurological deficits
c
The nurse is involved in a blood pressure clinic in the community, and an individual with possible stroke symptoms is brought for evaluation. Which findings in the F.A.S.T. assessment indicate the need to call emergency personnel? (Select all that apply.) a. The patient sways when asked to stand still with eyes closed. b. The patient is unable to follow directions during the assessment. c. The patient is unable to repeat a stated phrase exactly as it was stated. d. The patients face shows signs of uneven symmetry when asked to smile. e. When asked to close the eyes and hold arms straight in front, one arm drifts downward.
c, d, e
A client with a subarachnoid bleed refuses to use a bedpan and becomes angry when denied permission to walk to the bathroom. While waiting to hear from the health care provider (HCP), which action should the nurse take? a. Help the patient to get up on a bedside commode b. Wait for the neurosurgeon to call back with orders c. Page security to restrain the patient from harming the nurse d. Administer an as-needed dose of a sedative that is ordered
d
A patient has been prescribed pravastatin (Pravachol) to reduce cholesterol level after having a transient ischemic attack (TIA). What possible side effect should the nurse include when teaching the patient about this drug? a. Diarrhea b. Purple toe c. Confusion d. Muscle aches
d
A patient is experiencing bilateral hemiparesis, dysphasia, visual changes, and altered level of consciousness, ataxia, and dysphagia. Which artery was most likely affected in this patients stroke? a. Carotid b. Middle cerebral c. Posterior cerebral d. Vertebrobasilar/cerebellar
d
The nurse is assisting with teaching a patient who has had a transient ischemic attack (TIA). On which understanding should the nurse base teaching? a. TIAs are not serious, and the patient should have no further problems. b. A TIA is predictive that the patient will have a heart attack within 1 year. c. A TIA is a medical emergency that requires immediate surgical intervention. d. A TIA is a forewarning that the patient is at risk for a cerebrovascular accident (stroke).
d
The nurse suspects that a patient has vision changes caused by a stroke. What did the nurse assess to make this determination? a. Patient asks that all items be placed on the right side of the bed. b. Patient turns head away when blood is being drawn from an arm. c. Patient looks down at the floor when sitting on the side of the bed. d. Patient does not follow with the eyes as the nurse walks around the room.
d
The results of a carotid Doppler study indicate that a patient has stenosis of the left carotid artery. For which diagnostic test should the nurse prepare the patient to have completed next? a. MRI b. CT scan c. Echocardiogram d. Carotid angiography
d