NEURO NURSING MED SURG

What are the risk factors for Hemorrhagic Stroke 1.Hypertension 2.Smoking 3.Heavy alcohol use 4.Sympathetic nervous system stimulants 5. All of the above

5.All of the above

The nurse is receiving a report on a client who had a stroke. The outgoing nurse states, "Keep your eye on them, they keep trying to get up out of the bed and making really poor, impulsive decisions." The receiving nurse recognizes this as what kind of stroke?' 1.Right hemisphere 2.Left hemisphere 3.Frontal lobe 4.Occipital lobe

1. This client had a stroke in the right hemisphere of the brain because impulsivity, poor safety awareness, and impaired judgement are conducive of right sided injury. Left sided injury tends to have more language comprehension, facts, and logical reasoning deficits.

A client who has had a stroke is suffering from expressive aphasia. Which interventions would most likely improve communication with this client? 1.Try to use 'yes' or 'no' questions 2.Talk to the person in short words that a child would understand 3.Allow the person to embrace frustration when it occurs 4.Correct the person when he remembers something that is incorrect

1. Try to use 'yes' or 'no' questions- Aphasia may occur after a neurological injury such as a stroke. The person with aphasia has difficulty communicating and may be unable to express or receive information appropriately. The nurse should use 'yes' or 'no' questions to avoid putting stress on the client when they cannot give an answer in the form of a sentence. A closed-ended question can help the client if words cannot be formed, because the client can communicate by nodding.

Which of the following is the greatest risk factor for stroke? 1.Hypertension 2.Younger age 3.BMI 4.Elevated blood sugar

1.Hypertension - This is one of the highest indicator for a client to be at risk for a stroke. Obesity, diabetes mellitus, older age, smoking, and TIAs are some other, lesser, risk factors.

The nurse is caring for a client whose visiting spouse suddenly becomes confused and is noted to have aphasia. What is the priority concern for this person? 1.Stroke 2.Delirium 3.Sepsis 4.UTI

1.Stroke- Sudden-onset aphasia and confusion are a sign of a stroke. The nurse knows to assess for "FAST" - face, arms, speech, and time (meaning, time to treatment). This client is positive for the "S" in FAST, or speech. Signs and symptoms of stroke include confusion, slurred speech, facial drooping, one sided weakness, and pins and needles

Are you learning and having fun ? 1.yes 2.no

1.YES!!!

The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the plan of care? 1. Potential for injury. 2. Powerlessness. 3. Disturbed thought processes. 4. Sexual dysfunction.

2. Expressive aphasia means that the client cannot communicate thoughts but understands what is being communicated; this leads to frustration, anger, depression, and the inability to verbalize needs, which, in turn, causes the client to have a lack of control and feel powerless.

The nurse is assessing a client experiencing motor loss as a result of a left-sided cerebrovascular accident (CVA). Which clinical manifestation would the nurse document? 1. Hemiparesis of the client's left arm and apraxia. 2. Paralysis of the right side of the body and ataxia. 3. Homonymous hemianopsia and diplopia. 4. Impulsive behavior and hostility toward family.

2. The most common motor dysfunction of a CVA is paralysis of one side of the body, hemiplegia; in this case with a left-sided CVA, the paralysis would affect the right side. Ataxia is an impaired ability to coordinate movement

The nurse is planning care for a client experiencing agnosia secondary to a cerebrovascular accident. Which collaborative intervention will be included in the plan of care? 1. Observe the client swallowing for possible aspiration. 2. Position the client in a semi-Fowler's position when sleeping. 3. Place a suction setup at the client's bedside during meals. 4. Refer the client to an occupational therapist for evaluation.

4. A collaborative intervention is an intervention in which another health-care discipline—in this case, occupational therapy—is used in the care of the client

The client has been diagnosed with a cerebrovascular accident (stroke). The client's wife is concerned about her husband's generalized weakness. Which home modification should the nurse suggest to the wife prior to discharge? 1. Obtain a rubber mat to place under the dinner plate. 2. Purchase a long-handled bath sponge for showering. 3. Purchase clothes with Velcro closure devices. 4. Obtain a raised toilet seat for the client's bathroom.

4. Raising the toilet seat is modifying the home and addresses the client's weakness in being able to sit down and get up without straining muscles or requiring lifting assistance from the wife.