Chapter 62: management of patients with cerebrovascular disorders

a nurse is taking care of client with swallowing difficulties after a stroke. what are some interventions the nurse can accomplish to prevent the client from aspirating while eating? SATA a. encourage the client to increase his/her intake of water and juice b. assist the client out of bed and into the chair for meal c. instruct the client to tuck his/her chin towards their chest when swallowing d. request a swallowing assessment by a speech therapist before the client's discharge e. recommend the insertion of a precutaneous endoscopic gastrostomy (PEG) tube.

B, C

The nurse is discharging home a patient who suffered a stroke. He has a flaccid right arm and leg and is experiencing problems with urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common patient response to a change in body image? A) Denial B) Fear C) depression D) Disassociation

C. Depression depression is a common and serious problem in the client who has had a stroke. it results from a loss of independence.

a client is brought by ambulance to the ED after suffering what the family thinks is a stroke. the nurse caring for this client is aware that an absolute contraindication for thrombolytic therapy is what? a. evidence of hemorrhagic stroke b. blood pressure of 180/110 c. evidence of stroke evolution d. previous thrombolytic therapy with in the past 12 months

a. evidence of hemorrhagic stroke thrombolytic therapy would exacerbate a hemorrhagic stroke w/ potentially fatal consequences.

the nurse is assessing a client with a suspected stroke. what assessment finding is most suggestive of a stroke? a. facial droop b. dysrhythmias c. periorbital edema d. projectile vomiting

a. facial droop Remember BE FAST for stoke b-balance issues e-eye vision change f-facial drooping a-arm weakness s-speech slurring t-time to call 9-1-1

the nurse is educating a group of nursing students about covid-19 and risk for cerebrovascular disorders. the nurse educator notes that covid-19 has shown to increase which condition? a. ischemic stroke b. decrease inflammation c. hemorrhagic stroke d. hypertension

a. ischemic stroke C-19 causes blood clotting abnormalities

nursing care during the immediate recovery period from an ischemic stroke should normally prioritize which intervention? a. positioning the client to avoid intercranial pressure (ICP) b. maximizing partial pressure of carbon dioxide c. administering hypertonic intravenous solution d. initiating early mobilization

a. positioning the client to avoid intercranial pressure (ICP)

the client has been diagnosed with aphasia after suffering a stroke. what can the nurse do to make the client's atmosphere more conducive to communication? a. provide a board of commonly used needs and phrases. b. have the client speak to loved ones on the phone daily c. help the client complete his or her sentences as needed d. speak in a loud and deliberate voice to the client

a. provide a board of commonly used needs and phrases.

the nurse is educating a group of students about complications of an aneurysm. which is a complication of aneurysm? a. seizures b. hypernatremia c. airway collapse d. pneumothorax

a. seizures due to increased ICP, there is a risk for seizures

a client who suffered an ischemic stroke now has disturbed sensory perception. what principle should guide the nurse's care of this client? a. the client should be approached on the side where visual perception is intact. b. attention to the affected side should be minimized in order to decrease anxiety c. the client should avoid turning in the direction of the defective visual field to minimize shoulder subluxation d. the client should be approached on the opposite side of where the visual perception is intact to promote recovery

a. the client should be approached on the side where visual perception is intact.

a client who has experienced an ischemic stroke has been admitted to the medical unit. the client's family is adamant that the client remains on bed rest to hasten recovery and conserve energy. what principle of care should inform the nurse's response to the family? a. the client should mobilize as soon as physically able. b. to prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks. c. the client should remain on bed rest until the client expresses a desire to mobilize d. lack of mobility will greatly increase the client's risk of stroke recurrence.

a. the client should mobilize as soon as physically able. an active rehab program should be started to prevent complications.

which medication carries the greatest potential for reducing risk of stroke? a. naproxen b. calcium carbonate c. aspirin 81 mg d. lorazepam

aspirin

the nurse is caring for a client who had a hemorrhagic stroke. what assessment finding constitutes an early sign of deterioration? a. generalized pain b. alteration in LOC c. tonic-clonic seizures d. shortness of breath

b. alteration in LOC s/s include alteration in LOC, drowsiness, slurring speech, sluggish papillary reaction. Remember BE FAST for stoke b-balance issues e-eye vision change f-facial drooping a-arm weakness s-speech slurring t-time to call 9-1-1

what is a risk factor for cardiogenic embolic stroke? a. ventricular tachycardia b. atrial fibrillation c. supraventricular tachycardia d. bundle branch block

b. atrial fibrillation

a client recently had a stroke. now the client has spasms in his/her hands, which is preventing a favorite hobby of knitting. the client is looking for a permanent solution to this program. which therapies would the nurse recommend? a. botulinum toxin type A and heat b. baclofen and stretching c. amitriptyline and splinting d. corticosteroids and acupuncture

b. baclofen and stretching treatments: stretching, splinting, oral medications like baclofen, tizanidine.

when caring for a client who has had a stroke, a priority is reduction of ICP. what client position is most consistent with this goal? a. head turned slightly to the right side b. elevation of the head of the bed c. position changes every 15 min d. extension of the neck

b. elevation of the head of the bed elevation of the head of the bed promotes venous drainage and lowers ICP.

a client has recently begun mobilizing during the recovery from an ischemic stroke. to protect the client's safety during mobilization, the nurse should perform what action? a. support the client's full weight with a waist belt during ambulation b. have a colleague follow the client closely with a wheelchair c. avoid mobilizing the client in the early morning or late evening. d. ensure that the client's family members do not participate in mobilization

b. have a colleague follow the client closely with a wheelchair just in case the PT is fatigued or dizzy

a nurse is caring for a client diagnosed with a hemorrhagic stroke. when creating this client's plan of care, what goal should be prioritized? a. prevent complications of immobility b. maintain and improve cerebral tissue perfusion c. relieve anxiety and pain d. relieve sensory deprivation

b. maintain and improve cerebral tissue perfusion this is priority because it is need for the clients survival

a client with a recent stroke history is admitted to a rehabilitation unit and placed on high risk precautions. the client is impulsive, easily distracted, frequently forgets his/her cane when walking, and the location of his/her room. what stroke conditions do these signs best indicate? a. ischemic stroke b. right hemispheric stroke c. hemorrhagic stroke d. left hemispheric stroke

b. right hemispheric stroke in right hemispheric stroke, signs include a client that is easily distracted and has impulsive behavior and poor judgment.

a rapid response stroke code has been called for a client with DVT of the left leg being treated with intravenous heparin. INR: 2.1 t: 100.1 F HR: 102 BP: 190/100 R:14 O2: 89% on room air what are priority interventions for a client who is currently on anticoagulant therapy and having an ischemic stroke? a. immediate intubation and urinary catheter placement b. supplemental oxygen and monitoring blood glucose levels c. antipyretics in order to keep the client in a state of hypothermia d. antihypertensive medications and vital signs every two hours

b. supplemental oxygen and monitoring blood glucose levels careful maintenance of cerebral hemodynamics to maintain cerebral perfusion is extremely important after a stroke. reducing ICP is priority, measures include o2, and monitoring glucose levels.

the ischemic cascade happens in what order 1. change in ph 2. blood flow decreases 3. a switch to anaerobic respiration 4. membrane pumps fail 5. cells cease to function 6. lactic acid is generated. place the step in order: a. 6, 3, 5, 2, 4, 1 b. 3, 5, 2, 4, 1, 6 c. 2, 3, 6, 1, 4, 5 d. 1, 6, 2, 5, 3, 4

c. 2, 3, 6, 1, 4, 5

a nurse is assisting a client who had a recent stroke with getting dressed for physical therapy. the client looks at each piece of clothing before putting it on. the client states, "this is how i know what item i am holding." what impairment is this client likely experiencing? a. homonymous hemianopsia b. receptive aphasia c. agnosia d. hemiplegia

c. agnosia Agnosia is the loss of the ability to recognize objects through a particular sensory system, it may be visual, auditory, or tactile.

a client diagnosed with a hemorrhagic stroke has been admitted to the neurologic ICU. the nurse knows that teaching for the client and family needs to begin as soon as the client is settled on the unit and will continue until the client is discharged. what will the family education need to include? a. how to differentiate between hemorrhagic and ischemic stroke b. risk factors for ischemic stroke c. how to correctly modify the home environment d. techniques for adjusting the client's medication dosages at the home

c. how to correctly modify the home environment

the nurse is preparing health education for a client who is being discharged after hospitalization for a hemorrhagic stroke. what should the nurse include in this education? a. mild, intermittent seizures can be expected b. take ibuprofen for a serious headache c. take antihypertensive medication as prescribed d. drowsiness is normal for the first week after discharge

c. take antihypertensive medication as prescribed hypertension is the most serious risk factor and management is essential for a client being discharged.

the nurse is caring for a client diagnosed with an ischemic stroke and knows that effective positioning of the client is important. which of the following should be integrated into the client's care plan? a. the client's hip joint should be maintained in a flexed position b. the client should be in a supine position unless ambulating c. the client should be placed in a prone position for 15-30 minutes several times a day d. the client should be placed in a trendelenburg position two to three times daily to promote cerebral perfusion.

c. the client should be placed in a prone position for 15-30 minutes several times a day if this position is possible, it helps promote hyperextension of the hip joints, and helps prevent knee and hip flexion contractures. use a small pillow to support the pelvis.

a client with left hemispheric stroke is having difficulty with their normal speech pattern. the nurse is not sure whether the client has expressive aphasia or apraxia. which statement would most likely be reflective of apraxia? a. the nurse gives direction to get out of bed but the client does not understand b. the client points and gestures to an object needed on the overhead table c. the client starts by saying "good morning" but finishes with saying "good day" to the nurse d. the client sits up and turns to one side to see the object and states what is needed.

c. the client starts by saying "good morning" but finishes with saying "good day" to the nurse apraxia is an inability to perform a previously learned action as may be seen when a client makes verbal substitutions for desired syllables or words.

a client with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). what nursing intervention would be most appropriate for this client? a. passive range of motion exercises to prevent contractures b. supine positioning c. early initiation of physical therapy d. absolute bed rest in quiet, non stimulating environment

d. absolute bed rest in quiet, non stimulating environment the client is placed on immediate and absolute bed rest in a quiet, non-stressful environment because activity, pain, and anxiety elevates BP, which increases the risk of bleeding.

a client diagnosed with a cerebral aneurysm reports a severe headache to the nurse. what action is a priority for the nurse? a. sit with the client for a few minutes b. administer an analgesic c. inform the nurse manager d. call the health care provider

d. call the health care provider a headache may be an indication that the aneurysm is leaking.

a nurse is educating a group of nursing students about signs and symptoms of a hemorrhagic stroke. which is true of hemorrhagic stroke? a. occurs with vascular occlusion b. is also known as thrombotic stroke c. can be known as lacunar strokes. d. can occur in the subarachnoid space

d. can occur in the subarachnoid space

what should be included in the client's care plan when establishing an exercise program for a client affected by a stroke? a. schedule passive range of motion every other day b. keep activity limited, as the client may be overstimulated c. have the client perform active range of motion exercises once a day d. exercise the affected extremities passively four or five time a day

d. exercise the affected extremities passively four or five time a day this maintains joint mobility, regain control, prevent development of a contracture in the paralyzed extremity, prevent further deterioration of the neuromuscular system, and enhance circulation.

a client is diagnosed with right sided stroke. the client is now experiencing hemianopsia. how might the nurse help the client manage the potential sensory and perceptional difficulties? a. keep the lighting in the client's room low b. place the client's clock on the affected side. c. approach the client on the side where vision is impaired d. place the client's extremities where the client can see them.

d. place the client's extremities where the client can see them. homonymous hemianopsia (loss of half visual field) it is important for the nurse to remind the client constantly of the other side of the body, to maintain alignment of the extremities, and if possible, to place the extremities where the client can see them.

a client recovering from a stroke has severe shoulder pain from subluxation of the shoulder. to prevent further injury and pain, the nurse caring for this client is aware of what principle of care? a. the client should be fitted with a cast because the use of a sling should be avoided due to adduction of the affected shoulder b. elevation of the arm and hand can lead to further complications associated with edema c. passively exercising the affected extremity is avoided in order to minimize pain. d. the client should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to the shoulder.

d. the client should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to the shoulder.