Exam 5: Stroke NCLEX Quetions
a
A 32-year-old patient has a stroke resulting from a ruptured aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan? a. Applying intermittent pneumatic compression stockings b. Assisting to dangle on edge of bed and assess for dizziness c. Encouraging patient to cough and deep breathe every 4 hours d. Inserting an oropharyngeal airway to prevent airway obstruction
c d a b
A 58-year-old patient who began experiencing right-sided arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol? ____________________ a. Obtain CT scan without contrast. b. Infuse tissue plasminogen activator (tPA). c. Administer oxygen to keep O2 saturation >95%. d. Use National Institute of Health Stroke Scale to assess patient.
d
A 74-yr-old man who has right-sided extremity paralysis related to a thrombotic stroke develops constipation. Which action should the nurse take first? a. Assist the patient to the bathroom every 2 hours. b. Provide incontinence briefs to wear during the day. c. Administer a bisacodyl (Dulcolax) rectal suppository every day. d. Arrange for several servings per day of cooked fruits and vegetables.
a
A CT scan of a 68-yr-old male patient's head reveals that he has experienced a hemorrhagic stroke. What is the priority nursing intervention in the emergency department? a. Maintenance of the patient's airway b. Positioning to promote cerebral perfusion c. Control of fluid and electrolyte imbalances d. Administration of tissue plasminogen activator (tPA)
c
A carotid endarterectomy is being considered as treatment for a patient who has had several TIAs. What should the nurse explain to the patient about this surgery? a. it involves intracranial surgery to join a superficial extracranial artery to an intracranial artery b. it is used to restore blood circulation to the brain following an obstruction of a cerebral artery c. it involves removing an atherosclerotic plaque in the carotid artery to prevent an impending stroke d. it is used to open a stenosis in a carotid artery with a balloon and stent to restore cerebral circulation
1
A client who had a stroke needs to be fed. What instruction should the nurse give to the unlicensed assistive personnel (UAP) who will feed the client? 1. Position the client sitting up in bed before he or she is fed. 2. Check the client's gag and swallowing reflexes. 3. Feed the client quickly because there are three more clients to feed. 4. Suction the client's secretions between bites of food.
b
A diagnosis of a ruptured cerebral aneurysm has been made in a patient with manifestations of a stroke. The nurse anticipates which treatment option that would be considered for the patient? a. hyperventilation therapy b. surgical clipping of the aneurysm c. administration of hyperosmotic agents d. administration of thrombolytic therapy
b
A female patient has left-sided hemiplegia after an ischemic stroke 4 days earlier. How should the nurse promote skin integrity? a. Position the patient on her weak side the majority of the time. b. Alternate the patient's positioning between supine and side-lying. c. Avoid the use of pillows in order to promote independence in positioning. d. Establish a schedule for the massage of areas where skin breakdown emerges.
a
A newly admitted patient diagnosed with a right-sided brain stroke has a nursing diagnosis of disturbed visual sensory perception related to homonymous hemianopsia. Early in the care of the patient, what should the nurse do? a. place objects on the right side within the patient's field of vision b. approach the patient from the left side to encourage the patient to turn the head c. place objects on the patient's left side to assess the patient's ability to compensate d. patch the affected eye to encourage the patient to turn the head to scan the environment
c
A nurse is assessing a client. Which of the following findings indicates that the client has experienced a left-hemispheric stroke? a. impulse control difficulty b. poor judgement c. inability to recognize familiar objects d. loss of depth perception
a b c e
A nurse is caring for a client who has experienced right-hemispheric stroke. The nurse should expect the client to have difficulty with which of the following? (Select all that apply) a. impulse control b. moving the left side c. depth perception d. speaking e. situational awareness
a b e
A nurse is caring for a client who has global aphasia. Which of the following should the nurse include in the client's plan of care? (Select all that apply) a. speak to the client at a slower rate b. assist the client to use cards with pictures c. speak to the client in a loud voice d. complete sentences that the client cannot finish e. give instructions one step at a time
b
A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention? a. teach the client to scan to the right to see objects on the right side of the body b. place the bedside table on the right side of the bed c. orient the client to food on the plate using the clock method d. place the wheelchair on the client's left side
a b c e
A nurse is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care? (Select all that apply) a. have suction equipment ready for use b. feed the client thickened liquids c. place food on the unaffected side of the client's mouth d. assign an assistive personnel to feed the client slowly e. teach the client to swallow with the neck flexed
d
A patient comes to the emergency department immediately after experiencing numbness of the face and an inability to speak, but while the patient awaits examination, the symptoms disappear and the patient requests discharge. Why should the nurse emphasize that it is important for the patient to be treated before leaving? a. the patient has probably experienced an asymptomatic lacunar stroke b. the symptoms are likely to return and progress to worsening neurologic deficit in the next 24 hours c. neurologic deficits that are transient occur most often as a result of small hemorrhages that clot off d. the patient has probably experienced a transient ischemic attack, which is a sign of progressive cerebrovascular disease
c
A patient experiencing TIAs is scheduled for a carotid endarterectomy. The nurse explains that this procedure is done to a. decrease cerebral edema b. reduce the brain damage that occurs during a stroke in evolution c. prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow d. provide a circulatory bypass around thrombotic plaques obstructing cranial circulation
b
A patient has a stroke affecting the right hemisphere of the brain. Based on knowledge of the effects of right brain damage, the nurse establishes a nursing diagnosis of a. impaired physical mobility related to right hemiplegia. b. risk for injury related to denial of deficits and impulsiveness. c. impaired verbal communication related to speech-language deficits. d. ineffective coping related to depression and distress about disability.
c
A patient is admitted to the hospital with a left hemiplegia. To determine the size and location and to ascertain whether a stroke is ischemic or hemorrhagic, what will the nurse anticipate that the HCP will request? a. lumbar puncture b. cerebral angiography c. magnetic resonance imagine (MRI) d. computed tomography (CT) scan with contrast
b
A patient is admitted to the hospital with dysphasia and right-sided weakness that resolves in a few hours. The nurse will anticipate teaching the patient about a. alteplase (tPA). b. aspirin (Ecotrin). c. warfarin (Coumadin). d. nimodipine (Nimotop).
c
A patient is exhibiting word finding difficulty and weakness in his right arm. What area of the brain is most likely involved? a. brainstem b. vertebral artery c. left middle cerebral artery d. right middle cerebral artery
c
A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering the medications, the patient says, I dont need the aspirin today. I dont have any aches or pains. Which action should the nurse take? a. Document that the aspirin was refused by the patient. b. Tell the patient that the aspirin is used to prevent aches. c. Explain that the aspirin is ordered to decrease stroke risk. d. Call the health care provider to clarify the medication order.
c
A patient who has had a stroke has a new order to attempt oral feedings. The nurse should assess the gag reflex and then a. order a varied pureed diet. b. assess the patients appetite. c. assist the patient into a chair. d. offer the patient a sip of juice.
a
A patient who has had a subarachnoid hemorrhage is being cared for in the intensive care unit. Which information about the patient is most important to communicate to the health care provider? a. The patients blood pressure is 90/50 mm Hg. b. The patient complains about having a stiff neck. c. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs). d. The patient complains of an ongoing severe headache.
c
A patient who has right-sided weakness after a stroke is attempting to use the left hand for feeding and other activities. The patients wife insists on feeding and dressing him, telling the nurse, I just dont like to see him struggle. Which nursing diagnosis is most appropriate for the patient? a. Situational low self-esteem related to increasing dependence on others b. Interrupted family processes related to effects of illness of a family member c. Disabled family coping related to inadequate understanding by patients spouse d. Impaired nutrition: less than body requirements related to hemiplegia and aphasia
d
A patient with a history of several transient ischemic attacks (TIAs) arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. The nurse anticipates the need to prepare the patient for a. surgical endarterectomy. b. transluminal angioplasty. c. intravenous heparin administration. d. tissue plasminogen activator (tPA) infusion.
d
A patient with a left-sided brain stroke suddenly bursts into tears when family members visit. The nurse should a. use a calm voice to ask the patient to stop the crying behavior. b. explain to the family that depression is normal following a stroke. c. have the family members leave the patient alone for a few minutes. d. teach the family that emotional outbursts are common after strokes.
c
A patient with a right hemisphere stroke has a nursing diagnosis of unilateral neglect related to sensory-perceptual deficits. During the patient's rehabilitation, what nursing intervention is important for the nurse to do? a. avoid positioning the patient on the affected side b. place all objects for care on the patient's unaffected side c. teach the patient to care consciously for the affected side d. protect the affected side from injury with pillows and supports
d
A patient with a stroke experiences right-sided arm and leg paralysis and facial drooping on the right side. When admitting the patient, which clinical manifestation will the nurse expect to find? a. Impulsive behavior b. Right-sided neglect c. Hyperactive left-sided reflexes d. Difficulty in understanding commands
c
A patient with a stroke has a right-sided hemiplegia. What does the nurse teach the family to prepare them to cope with the behavior changes seen with this type of stroke? a. ignore undesirable behaviors manifested by the patient b. provide directions to the patient verbally in small steps c. distract the patient from inappropriate emotional responses d. supervise all activities before allowing the patient to pursue them independently
d
A patient with a stroke has progressive development of neurologic deficits with increasing weakness and decreased level of consciousness (LOC). Which nursing diagnosis has the highest priority for the patient? a. Impaired physical mobility related to weakness b. Disturbed sensory perception related to brain injury c. Risk for impaired skin integrity related to immobility d. Risk for aspiration related to inability to protect airway
a
A patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? a. Check the respiratory rate. b. Monitor the blood pressure. c. Send the patient for a CT scan. d. Obtain the Glasgow Coma Scale score.
d
A patient with right-sided weakness that started 90 minutes earlier is admitted to the emergency department and all these diagnostic tests are ordered. Which test should be done first? a. Electrocardiogram (ECG) b. Complete blood count (CBC) c. Chest radiograph (Chest x-ray) d. Noncontrast computed tomography (CT) scan
d
A patient with sudden-onset right-sided weakness has a CT scan and is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? a. The patients speech is difficult to understand. b. The patients blood pressure is 144/90 mm Hg. c. The patient takes a diuretic because of a history of hypertension. d. The patient has atrial fibrillation and takes warfarin (Coumadin).
d
A patient's wife asks the nurse why her husband did not receive the clot busting medication (tissue plasminogen activator) she has been reading about. Her husband is diagnosed with a hemorrhagic stroke. What is the best response by the nurse to the wife? a. "He didn't arrive within the timeframe for that therapy." b. "Not everyone is eligible for this drug. Has he had surgery lately?'" c. "You should discuss the treatment of your husband with his doctor." d. "The medication you are talking about dissolves clots and could cause more bleeding in your husband's brain."
c
A thrombus that develops in a cerebral artery does not always cause a loss of neurologic function because a. the body can dissolve atherosclerotic plaques as they form b. some tissues of the brain do not require constant blood supply to prevent damage c. circulation via the Circle of Willis may provide blood supply to the affected area of the brain d. neurologic deficits occur only when major arteries are occluded by thrombus formation around atherosclerotic plaque
a
After receiving change-of-shift report on the following four patients, which patient should the nurse see first? a. A patient with right-sided weakness who has an infusion of tPA prescribed b. A patient who has atrial fibrillation and a new order for warfarin (Coumadin) c. A patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due d. A patient with a subarachnoid hemorrhage 2 days ago who has nimodipine (Nimotop) scheduled
d
As one of your clinical assignments, you are assisting an RN with health screening at a health fair. Which individual is at greatest risk for experiencing a stroke? a.A 46-year-old white female with hypertension and oral contraceptive use for 10 years b.A 58-year-old white male salesman who has a total cholesterol level of 285 mg/dl c.A 42-year-old African American female with diabetes mellitus who has smoked for 30 years d.A 62-year-old African American male with hypertension who is 35 pounds overweight
c
Aspirin is ordered for a patient who is admitted with a possible stroke. Which information obtained during the admission assessment indicates that the nurse should consult with the health care provider before giving the aspirin? a. The patient has dysphasia. b. The patient has atrial fibrillation. c. The patient states, My symptoms started with a terrible headache. d. The patient has a history of brief episodes of right-sided hemiplegia.
c
Bladder training in a male patient who has urinary incontinence after a stroke includes a. limiting fluid intake b. keeping a urinal in place at all times c. assisting the patient to stand to void d. catheterizing the patient every 4 hours
a d e
Common psychosocial reactions of the stroke patient to the stroke include (Select all that apply) a. depression b. disassociation c. intellectualization d. sleep disturbances e. denial of severity of stroke
a
During the acute phase of a stroke, the nurse assesses the patient's vital signs and neurologic status at least every 4 hours. What is a cardiovascular sign that the nurse would see as the body attempts to increase cerebral blood flow? a. hypertension b. fluid overload c. cardiac dysrhythmias d. S3 and S4 heart sounds
a b c d f
During the secondary assessment of the patient with a stroke, what should be included? (Select all that apply) a. gaze b. sensation c. facial palsy d. proprioception e. current medications f. distal motor function
b
For a patient who is suspected of having a stroke, one of the most important pieces of information that the nurse can obtain is a. time of the patient's last meal b. time at which stroke symptoms first appeared c. patient's hypertension history and management d. family history of stroke and other cardiovascular diseases
a
Four days following a stroke, a patient is to start oral fluids and feedings. Before feeding the patient, what should the nurse do first? a. check the patient's gag reflex b. order a soft diet for the patient c. raise the had of bed to a sitting position d. evaluate the patient's ability to swallow small amounts of crushed ice or ice water
c
In promoting health maintenance for prevention of strokes, the nurse understands that the highest risk for the most common type of stroke is present in which people? a. african americans b. women who smoke c. individuals with hypertension and diabetes d. those who are obese with high dietary fat intake
d
Information provided by the patient that would help differentiate a hemorrhagic stroke from a thrombotic stroke includes a. sensory disturbance b. a history of hypertension c. presence of motor weakness d. sudden onset of severe headache
d
Of the following patients, the nurse recognizes that the one with the highest risk for a stroke is a. obese 45 year old Native American b. 35 year old Asian American woman who smokes c. 32 year old white woman taking oral contraceptives d. 65 year old African American man with hypertension
c
P.D. is diagnosed with a thrombotic stroke. Over the next 72 hours, you plan care with the knowledge that he a. is ready for aggressive rehabilitation. b. will show gradual improvement of the initial neurologic deficits. c. may show signs of deteriorating neurologic function as cerebral edema increases. d. should not be turned or exercised to prevent extension of the thrombus and increased neurologic deficits.
b
Several weeks after a stroke, a patient has urinary incontinence resulting from an impaired awareness of bladder fullness. For an effective bladder training program, which nursing intervention will be best to include in the plan of care? a. Limit fluid intake to 1200 mL daily to reduce urine volume. b. Assist the patient onto the bedside commode every 2 hours. c. Perform intermittent catheterization after each voiding to check for residual urine. d. Use an external condom catheter to protect the skin and prevent embarrassment.
1
The RN is supervising a senior nursing student who is caring for a client with a right hemisphere stroke. Which action by the student nurse requires that the RN intervene? 1. Instructing the client to sit up straight and the client responds with a puzzled expression 2. Moving the client's food tray to the right side of his over-bed table 3. Assisting the client with passive range-of-motion (ROM) exercises 4. Combing the hair on the left side of the client's head when the client always combs his hair on the right side
c
The factor related to cerebral blood flow that most often determines the extent of cerebral damage from a stroke is the a. amount of cardiac output b. O2 content of the blood c. degree of collateral circulation d. level of CO2 in the blood
d
The female patient has been brought to the emergency department complaining of the most severe headache of her life. Which type of stroke should the nurse anticipate? a. TIA b. Embolic stroke c. Thrombotic stroke d. Subarachnoid hemorrhage
b
The health care provider prescribes clopidogrel (Plavix) for a patient with cerebral atherosclerosis. When teaching about the new medication, the nurse will tell the patient a. to monitor and record the blood pressure daily. b. to call the health care provider if stools are tarry. c. that Plavix will dissolve clots in the cerebral arteries. d. that Plavix will reduce cerebral artery plaque formation.
a
The health care provider recommends a carotid endarterectomy for a patient with carotid atherosclerosis and a history of transient ischemic attacks (TIAs). The patient asks the nurse to describe the procedure. Which response by the nurse is appropriate? a. The carotid endarterectomy involves surgical removal of plaque from an artery in the neck. b. The diseased portion of the artery in the brain is removed and replaced with a synthetic graft. c. A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed. d. A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque.
d
The incidence of ischemic stroke in patients with TIAs and other risk factors is reduced with the administration of which medication? a. nimodipine b. furosemide (lasix) c. warfarin (coumadin) d. daily low-dose aspirin
d
The nurse can best assist the patient and family in coping with the long-term effects of a stroke by doing what? a. informing family members that the patient will need assistance with almost all ADLs b. explaining that the patient's prestroke behavior will return as improvement progresses c. encouraging the patient and family members to seek assistance from family therapy or stroke support groups d. helping the patient and family to understand the significance of residual stroke damage to promote problem solving and planning
c
The nurse expects that management of the patient who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects will include a. prophylactic clipping of cerebral aneurysms. b. heparin via continuous intravenous infusion. c. oral administration of low dose aspirin therapy. d. therapy with tissue plasminogen activator (tPA).
c
The nurse explains to the patient with a stroke who is scheduled for angiography that this test is used to determine the a. presence of increased ICP b. site and size of the infarction c. patency of the cerebral blood vessels d. presence of blood in the cerebrospinal fluid
c
The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to impaired self-feeding ability for a patient with right-sided hemiplegia. Which intervention should be included in the plan of care? a. Provide a wide variety of food choices. b. Provide oral care before and after meals. c. Assist the patient to eat with the left hand. d. Teach the patient the chin-tuck technique.
b
The nurse identifies the nursing diagnosis of impaired verbal communication for a patient with expressive aphasia. An appropriate nursing intervention to help the patient communicate is to a. have the patient practice facial and tongue exercises. b. ask simple questions that the patient can answer with yes or no. c. develop a list of words that the patient can read and practice reciting. d. prevent embarrassing the patient by changing the subject if the patient does not respond.
d
The nurse in a primary care provider's office is assessing several patients today. Which patient is most at risk for a stroke? a. A 92-yr-old female patient who takes warfarin (Coumadin) for atrial fibrillation b. A 28-yr-old male patient who uses marijuana after chemotherapy to control nausea c. A 42-yr-old female patient who takes oral contraceptives and has migraine headaches d. A 72-yr-old male patient who has hypertension and diabetes mellitus and smokes tobacco
b
The nurse is caring for a patient with carotid artery narrowing who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse? a. The pulse rate is 104 beats/min. b. The patient has difficulty talking. c. The blood pressure is 142/88 mm Hg. d. There are fine crackles at the lung bases.
a b d e
The nurse is discharging a patient admitted with a transient ischemic attack (TIA). For which medications might the nurse expect to provide discharge instructions? (Select all that apply) a. Ticlopidine b. Clopidogrel c. Enoxaparin d. Dipyridamole e. Enteric-coated aspirin f. Tissue plasminogen activator (tPA)
c
The nurse is planning psychosocial support for the family of the patient who suffered a stroke. What factor will have the greatest impact on family coping? a. Specific patient neurologic deficits b. The patient's ability to communicate c. Rehabilitation potential of the patient d. Presence of complications of a stroke
3
The nurse is providing care for a client with an acute hemorrhagic stroke. The client's spouse tells the nurse that he has been reading a lot about strokes and asks why his wife has not received alteplase. What is the nurse's best response? 1. "Your wife was not admitted within the time frame that alteplase is usually given." 2. "This drug is used primarily for clients who experience an acute heart attack." 3. "Alteplase dissolves clots and may cause more bleeding into your wife's brain." 4. "Your wife had gallbladder surgery just 6 months ago, so we can't use alteplase."
d
The nurse is teaching a senior citizen's group about signs and symptoms of a stroke. Which statement by the nurse would provide accurate information? a. "Take the person to the hospital if a headache lasts for more than 24 hours." b. "Stroke symptoms usually start when the person is awake and physically active." c. "A person with a transient ischemic attack has mild symptoms that will go away." d. "Call 911 immediately if a person develops slurred speech or difficulty speaking."
d
The nurse observes a student nurse assigned to initiate oral feedings for a 68-yr-old woman with an ischemic stroke. Which action by the student will require the nurse to intervene? a. Giving the patient 1 oz of water to swallow b. Telling the patient to perform a chin tuck before swallowing c. Assisting the patient to sit in a chair before feeding the patient d. Assessing cranial nerves III, IV, and VI before attempting feeding
d
The nurse obtains all of the following information about a 65-year-old patient in the clinic. When developing a plan to decrease stroke risk, which risk factor is most important for the nurse to address? a. The patient has a daily glass of wine to relax. b. The patient is 25 pounds above the ideal weight. c. The patient works at a desk and relaxes by watching television. d. The patients blood pressure (BP) is usually about 180/90 mm Hg.
c
The nurse receives a verbal report that a patient has an occlusion of the left posterior cerebral artery. The nurse will anticipate that the patient may have a. dysphasia. b. confusion. c. visual deficits. d. poor judgment.
b
The nurse would expect to find what clinical manifestation in a patient admitted with a left-sided stroke? a. Impulsivity b. Impaired speech c. Left-side neglect d. Short attention span
c
The patient has a lack of comprehension of both verbal and written language. Which type of communication difficulty does this patient have? a. dysarthria b. fluent dysphagia c. receptive aphasia d. expressive aphasia
a
The patient with diabetes mellitus had a right-sided stroke. Which nursing intervention should the nurse plan to provide for this patient? a. Safety measures b. Patience with communication c. Mobility assistance on the right side d. Place food in the left side of patient's mouth.
c d f
The rehabilitation nurse assesses the patient, caregiver, and family before planing the rehabilitation program for this patient. What must be included in this assessment? (Select all that apply) a. cognitive status of the family b. patient resources and support c. physical status of all body systems d. rehabilitation potential of the patient e. body strength remaining after the stroke f. patient and caregiver expectations of the rehabilitation
a b c e
What are characteristics of a stroke caused by an intracerebral hemorrhage? (Select all that apply) a. carries a poor prognosis b. caused by rupture of a vessel c. strong association with hypertension d. commonly occurs during or after sleep e. creates a mass that compresses the brain
d
What is a nursing intervention that is indicated for the patient with hemiplegia? a. the use of a footboard to prevent plantar flexion b. immobilization of the affected arm against the chest with a sling c. positioning the patient in bed with each joint lower than the joint proximal to it d. having the patient perform passive range of motion of the affected limb with the unaffected limb
d
What is a priority intervention in the ED for a patient with a stroke? a. IV fluid replacement b. administration of osmotic diuretics to reduce cerebral edema c. initiation of hypothermia to decrease the oxygen needs of the brain d. maintenance of respiratory function with a patent airway and oxygen administration
c
What is an appropriate food for a patient with a stroke who has mild dysphagia? a. fruit juices b. pureed meat c. scrambled eggs d. fortified milkshakes
a
What is an appropriate nursing intervention to promote communication during rehabilitation of the patient with aphasia? a. allow time for the individual to complete their thoughts b. use gestures, pictures, and music to stimulate patient responses c. structure statements so that the patient does not have to respond verbally d. use flashcards with simple words and pictures to promote recall of language
c
What primarily determines the neurologic functions that are affected by a stroke? a. the amount of tissue area involved b. the rapidity of the onset of symptoms c. the brain area perfused by the affected artery d. the presence or absence of collateral circulation
d
When assessing a patient with a possible stroke, the nurse finds that the patients aphasia started 3.5 hours previously and the blood pressure is 170/92 mm Hg. Which of these orders by the health care provider should the nurse question? a. Infuse normal saline at 75 mL/hr. b. Keep head of bed elevated at least 30 degrees. c. Administer tissue plasminogen activator (tPA) per protocol. d. Titrate labetolol (Normodyne) drip to keep BP less than 140/90 mm Hg.
c
When caring for a patient with left-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care during the acute period of the stroke? a. Apply an eye patch to the left eye. b. Approach the patient from the left side. c. Place objects needed for activities of daily living on the patients right side. d. Reassure the patient that the visual deficit will resolve as the stroke progresses.
c
When providing care to the patient with an acute stroke, which duty can be delegated to the LPN/LVN? a. Screen patient for tPA eligibility. b. Assess the patient's ability to swallow. c. Administer scheduled anticoagulant medications. d. Place equipment needed for seizure precautions in room.
1 2 3 5 6
Which actions should the nurse delegate to an experienced unlicensed assistive personnel (UAP) when caring for a client with a thrombotic stroke who has residual left-sided weakness? (Select all that apply) 1. Assisting the client to reposition every 2 hours 2. Reapplying pneumatic compression boots 3. Reminding the client to perform active range-of-motion (ROM) exercises 4. Assessing the extremities for redness and edema 5. Setting up meal trays and assisting with feeding 6. Using a lift to assist the client up to a bedside chair
d
Which intervention is most appropriate when communicating with a patient with aphasia after a stroke? a. Present several thoughts at once so that the patient can connect the ideas. b. Ask open-ended questions to provide the patient the opportunity to speak. c. Finish the patient's sentences to minimize frustration associated with slow speech. d. Use simple, short sentences accompanied by visual cues to enhance comprehension.
c
Which intervention should the nurse delegate to the licensed practical nurse when caring for a patient following an acute stroke? a. assess the patient's neurologic status b. assess the patient's gag reflex before beginning feeding c. administer ordered antihypertensives and platelet inhibitors d. teach the patient's caregivers strategies to minimize unilateral neglect
a
Which modifiable risk factor for stroke would be most important for the nurse to include when planning a community education program? a. Hypertension b. Hyperlipidemia c. Alcohol consumption d. Oral contraceptive use
c
Which of these nursing actions included in the care of a patient who has been experiencing stroke symptoms for 60 minutes can the nurse delegate to an LPN/LVN? a. Assess the patients gag and cough reflexes. b. Determine when the stroke symptoms began. c. Administer the prescribed clopidogrel (Plavix). d. Infuse the prescribed IV metoprolol (Lopressor).
c
Which sensory-perceptual deficit is associated with left-sided stroke (right hemiplegia)? a. Overestimation of physical abilities b. Difficulty judging position and distance c. Slow and possibly fearful performance of tasks d. Impulsivity and impatience at performing tasks
a
Which type of stroke is associated with endocardial disorders, has a rapid onset, and is likely to occur during activity? a. embolic b. thrombotic c. intracerebral hemorrhage d. subarachnoid hemorrhage
