Chapter 67 PrepU
A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the health care provider in the emergency department. Which is the origin of the client's symptoms? A impaired cerebral circulation B cardiac disease C diabetes insipidus D hypertension
A
A client admitted to the emergency department is being evaluated for the possibility of a stroke. Which assessment finding would lead the nurse to suspect that the client is experiencing a hemorrhagic stroke? A severe exploding headache B left-sided weakness C slurred speech D difficulty finding appropriate words
A
A client has experienced an ischemic stroke that has damaged the frontal lobe of his brain. Which of the following deficits does the nurse expect to observe during assessment? A Limited attention span and forgetfulness B Hemiplegia or hemiparesis C Lack of deep tendon reflexes D Visual and auditory agnosia
A
A client has experienced an ischemic stroke that has damaged the frontal lobe of his brain. Which of the following deficits does the nurse expect to observe during assessment? A Limited attention span and forgetfulness B Hemiplegia or hemiparesis C Lack of deep tendon reflexes DVisual and auditory agnosia
A
A client has just been diagnosed with an aneurysm. In planning discharge teaching for this client, what instructions should be delivered by the nurse to the client? Avoid heavy lifting. Include peanut butter, bread, or tart foods in the diet. Take opioid analgesics. Take an herbal form of feverfew.
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 prescribed medications. C Administer preoperative sedation. D Administer an osmotic diuretic.
A
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 immediately B in 2 to 3 days C after 1 week D upon transfer to a rehabilitation unit
A
A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? A Heparin sodium B Dexamethasone C Methyldopa D Phenytoin
A
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 "Emotional lability is common after a stroke, and it usually improves with time." 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 "This behavior is common in clients with stroke. Which does your spouse do more often? Laugh or cry?"
A
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 Thrombolytic therapy has a time window of only 3 hours. B A ruptured intracranial aneurysm must quickly be repaired. C Intracranial pressure is increased by a space-occupying bleed. D A ruptured arteriovenous malformation will cause deficits until it is stopped.
A
A nurse practitioner provides health teaching to a patient who has difficulty managing hypertension. This patient is at an increased risk of which type of stroke? A Intracerebral hemorrhage B Subarachnoid hemorrhage C Hemorrhage due to an aneurysm D Arteriovenous malformation
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
A stroke victim is experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe? A Frontal B Occipital C Parietal D Temporal
A
An emergency department nurse is interviewing a client who is presenting with signs of an ischemic stroke that began 2 hours ago. The client reports a history of a cholecystectomy 6 weeks ago and is taking digoxin, warfarin, and labetalol. What factor poses a threat to the client for thrombolytic therapy? A International normalized ratio greater than 2 B Two hour time period of the stroke C Taking digoxin D Surgery 6 weeks ago
A
Aneurysm rebleeding occurs most frequently during which time frame after the initial hemorrhage? A First 12 hours B First 24 hours C First 48 hours D First 72 hours
A
The nurse is caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke does the nurse know this client has? A Ischemic B Hemorrhagic C Right-sided D Left-sided
A
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 Psychosis, disorientation, delirium, insomnia, and hallucinations B Severe dementia and myoclonus C Tremor, rigidity, and bradykinesia D Choreiform movement and dementia
A
The nurse is providing information about strokes to a community group. Which of the following would the nurse identify as the primary initial symptoms of an ischemic stroke? A Weakness on one side of the body and difficulty with speech B Severe headache and early change in level of consciousness C Foot drop and external hip rotation D Vomiting and seizures
A
The provider diagnoses the patient as having had an ischemic stroke. The etiology of an ischemic stroke would include which of the following? A Cardiogenic emboli B Cerebral aneurysm C Arteriovenous malformation D Intracerebral hemorrhage
A
What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke? A Left visual field deficit B Aphasia C Slow, cautious behavior D Altered intellectual ability
A
Which of the following is accurate regarding a hemorrhagic stroke? A Main presenting symptom is an "exploding headache." B Functional recovery usually plateaus at 6 months. C One of the main presenting symptoms is numbness or weakness of the face. D It is caused by a large-artery thrombosis.
A
Which of the following is the chief cause of intracerebral hemorrhage (ICH)? A Uncontrolled hypertension B Diabetes C Hypercholesterolemia D Migraine headaches
A
Which of the following is the initial diagnostic in suspected stroke? A Noncontrast computed tomography (CT) B CT with contrast C Magnetic resonance imaging (MRI) D Cerebral angiography
A
Which of the following is the most common side effect of tissue plasminogen activator (tPA)? A Bleeding B Headache C Increased intracranial pressure (ICP) D Hypertension
A
Which of the following, if left untreated, can lead to an ischemic stroke? A Atrial fibrillation B Cerebral aneurysm C Arteriovenous malformation (AVM) D Ruptured cerebral arteries
A
The nurse knows that symptoms associated with a TIA, usually a precursor of a future stroke, usually subside in what period of time? A 1 hour B 3 to 6 hours C 12 hours D 24 to 36 hours
A A transient ischemic attack (TIA) is a neurologic deficit typically lasting less than 1 hour. A TIA is manifested by a sudden loss of motor, sensory, or visual function. The symptoms result from temporary ischemia (impairment of blood flow) to a specific region of the brain; however, when brain imaging is performed, there is no evidence of ischemia.
A client is experiencing severe pain related to increased ICP. Which analgesic would be ordered for this client to help alleviate pain? A codeine B hydrocodone C morphine D fentanyl
A Avoid administering opioid analgesics, except codeine. Opioids interfere with accurate assessment of neurologic function because they constrict the pupils and depress LOC.
Which are contraindications for the administration of tissue plasminogen activator (t-PA)? Select all that apply. A Intracranial hemorrhage B Ischemic stroke C Age 18 years or older D Systolic BP less than or equal to 185 mm Hg E Major abdominal surgery within 10 days
A, E
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 best alternative medication to give is A dipyridamole. B aspirin. C clopidogrel. D ticlopidine.
B
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 Transient ischemic attack (TIA) B Left-sided cerebrovascular accident (CVA) C Right-sided cerebrovascular accident (CVA) D Completed Stroke
B
A client recently experienced a stroke with accompanying left-sided paralysis. His family voices concerns about how to best interact with him. They report the client doesn't seem aware of their presence when they approach him on his left side. What advice should the nurse give the family? A "The client is feeling an emotional loss. He'll eventually start acknowledging you on his left side." B "The client is unaware of his left side. You should approach him on the right side." C "The client is unaware of his left side. You need to encourage him to interact from this side." D "This condition is temporary."
B
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 Nausea, vomiting, and profuse sweating B Hemiplegia, seizures, and decreased level of consciousness C Difficulty breathing or swallowing D Tachycardia, tachypnea, and hypotension
B
A client who complains of recurring headaches, accompanied by increased irritability, photophobia, and fatigue is asked to track the headache symptoms and occurrence on a calendar log. Which is the best nursing rationale for this action? A Cluster headaches can cause severe debilitating pain. B Migraines often coincide with menstrual cycle. C Tension headaches are easier to treat. D Headaches are the most common type of reported pain.
B
A client with CVA is prescribed medication to treat the disorder. The client wants to know what other measures may help reduce CVA. Which is an accurate suggestion for the client? A Increase body weight moderately B Reduce hypertension and high blood cholesterol C Increase intake of proteins and carbohydrates D Increase hydration and the intake of fluids
B
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 Cholesterol-lowering drugs B Anticoagulant therapy C Monthly prothrombin levels D Carotid endarterectomy
B
A critical care nurse is caring for a client with a cerebrovascular accident (CVA) The client is prescribed heparin for treatment. The nurse knows to monitor the client for what adverse effects? A Migraine attacks B Hemorrhage C Respiratory distress D High blood pressure
B
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 Positioning the client to prevent airway obstruction B Keeping the client in one position to decrease bleeding C Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess D Maintaining the client in a quiet environment
B
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 Diphenhydramine (Benadryl) B Lioresal (Baclofen) C Heparin D Pregabalin (Lyrica)
B
The nurse is caring for a client with aphasia. Which strategy will the nurse use to facilitate communication with the client? A Speaking loudly B Establishing eye contact C Avoiding the use of hand gestures D Speaking in complete sentences
B
Which clinical manifestation would be exhibited by a client following a hemorrhagic stroke of the right hemisphere? A Inability to move the right arm B Neglect of the left side C Neglect of the right side D Expressive aphasia
B
Which is a nonmodifiable risk factor for ischemic stroke? A Atrial fibrillation B Gender C Hyperlipidemia D Smoking
B
While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are: A Weakness on one side of the body and difficulty with speech B Severe headache and early change in level of consciousness C Foot drop and external hip rotation D Confusion or change in mental status
B
Which is indicative of a right hemisphere stroke? A Aphasia B Spatial-perceptual deficits C Slow, cautious behavior D Altered intellectual ability
B Clients with right hemisphere stroke exhibit partial perceptual deficits, left visual field deficit, and paralysis with weakness on the left side of the body. Left hemisphere damage causes aphasia; slow, cautious behavior; and altered intellectual ability.
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 Limited attention span and forgetfulness B Visual agnosia C Lack of deep tendon reflexes D Auditory agnosia
C
A client is admitted for evaluation of cerebral aneurysm. Which assessment finding is of greatest importance in prioritizing nursing care to this client? A Complaint of headache off and on for past month B No bowel movement since yesterday C Nausea D Frequent voiding
C
A nurse is reading a journal article about stroke and the underlying causes associated with this condition. The nurse demonstrates understanding of the information when identifying which subtype of stroke as being due to atrial fibrillation? A large-artery thrombotic B small, penetrating artery thrombotic C cardio embolic D cryptogenic
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 Numbness of an arm or leg B Double vision C Severe headache D Dizziness and tinnitus
C
A patient suffering a stroke is having a difficult time swallowing. What would the nurse document this finding as? A Ataxia B Arthralgia C Dysphagia D Dysarthria
C
The nurse is caring for a client with chronic migraines who is prescribed medication. What drug-related instructions should the nurse give the client? A Take medication just before going to bed at night. B Take medication only when migraine is intense. C Take medication as soon as symptoms of the migraine begin. D Take medication only during the morning when it's calm and quiet.
C
A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to do perform which action? A Comprehend spoken words B Form understandable words C Form understandable words and comprehend spoken words D Speak at all
C Global aphasia is a combination of expressive and receptive aphasia and presents a tremendous challenge to the nurse to communicate effectively with the client. In receptive and expressive aphasia, the client is unable to form words that are understandable. The client who is unable to speak at all is referred to as mute.
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? A 2:00 p.m. B 3:00 p.m. C 4:00 p.m. D 7:00 p.m.
C Tissue plasminogen activator (tPA) must be given within 3 hours after symptom onset. Therefore, since symptom onset was 1:00 pm, the window of opportunity ends at 4:00 pm.
A client is brought to the emergency department in a confused state, with slurred speech, characteristics of a headache, and right facial droop. The vital signs reveal a blood pressure of 170/88 mm Hg, pulse of 92 beats/minute, and respirations at 24 breaths/minute. On which bodily system does the nurse focus the nursing assessment? A Cardiovascular system B Respiratory system C Endocrine system D Neurovascular system
D
A client is hospitalized when presenting to the emergency department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to his presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what? A Left-sided stroke B Right-sided stroke C Cerebral aneurysm D Transient ischemic attack
D
After a stroke, a client is admitted to the facility. The client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g. Which nursing intervention is a priority for this client? Checking stools for occult blood Performing range-of-motion (ROM) exercises on the left side Keeping skin clean and dry Elevating the head of the bed to 30 degrees
D
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 Heart rate of 100 B Respiration of 22 C Systolic pressure of 130 mm Hg D Diastolic pressure of 110 mm Hg
D
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 BMonitoring for seizure activity CAdministering a stool softener DMaintaining a patent airway
D
The nurse is caring for a client with a history of transient ischemic attacks (TIAs) and moderate carotid stenosis who has undergone a carotid endarterectomy. Which postoperative finding would cause the nurse the most concern? A Neck pain rated 3 of 10 (on a 0 to 10 pain scale) B Blood pressure 128/86 mm Hg C Mild neck edema D Difficulty swallowing
D
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 Supine D Semi-Fowler's
D
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 Thyroid disease B Social drinking C Advanced age D Smoking
D
When communicating with a client who has sensory (receptive) aphasia, the nurse should: A allow time for the client to respond. B speak loudly and articulate clearly. C give the client a writing pad. D use short, simple sentences.
D
When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke? The day before the patient is discharged After the patient has passed the acute phase of the stroke After the nurse has received the discharge orders The day the patient has the stroke
D
Which terms refers to blindness in the right or left half of the visual field in both eyes? A Scotoma B Diplopia C Nystagmus D Homonymous hemianopsia
D
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 Obesity B Dyslipidemia C Smoking D Hypertension
D Hypertension is the most modifiable risk factor for either ischemic or hemorrhagic stroke. Unfortunately, it remains under-recognized and undertreated in most communities.
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? spouse chaplain home care nurse physical therapist
a
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 12-lead electrocardiogram b Carotid ultrasound study c Noncontrast computed tomogram d Transcranial Doppler flow study
c
