med surg neuro

Evaluating the level of consciousness using the Glasgow Coma Scale is an essential nursing assessment for a patient who has had an intracerebral hemorrhage. Which of the following scores would indicate the need for immediate intubation?

8

A nurse is assisting with a community screening for people at high risk for stroke. To which of the following clients would the nurse pay most attention?

A 60-year-old African-American man

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 thrombus formation at the site of the endarterectomy

Which term refers to the failure to recognize familiar objects perceived by the senses?

Agnosia

A patient who just suffered a hemorrhagic stroke is brought to the emergency department by ambulance. What should be the nurse's primary assessment focus?

Cardiac and respiratory status

A nurse practitioner is presenting health information about strokes at a clinic. She mentions that there are five categories of strokes based on their origin. Which of the following is the category that has the highest incidence of strokes (30%)?

Cryptogenic

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?

Difficulty swallowing

A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to perform which action?

Form words that are understandable or comprehend spoken words

A client is receiving an IV infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant?

Increased urine output

A nurse is planning discharge for a client who experienced right-sided weakness caused by a stroke. During his hospitalization, the client has been receiving physical therapy, occupational therapy, and speech therapy daily. The family voices concern about rehabilitation after discharge. How should the nurse intervene?

Inform the case manager of the family's concern and provide information about the client's current clinical status so appropriate resources can be provided after discharge.

What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke?

Left visual field deficit

The nurse is providing diet-related advice to a male patient following a cerebrovascular accident (CVA). The patient wants to minimize the volume of food and yet meet all nutritional elements. Which of the following suggestions should the nurse give to the patient about controlling the volume of food intake?

Provide thickened commercial beverages and fortified cooked cereals.

A nurse is teaching a community group about modifiable and nonmodifiable risk factors for ischemic strokes. Which of the following is a risk factor that cannot be modified?

advanced age

An emergency department nurse is awaiting the arrival of a client with signs of an ischemic stroke that began 1 hour ago, as reported by emergency medical personnel. The treatment window for thrombolytic therapy is which of the following?

three hours

The nurse is aware that in an ischemic stroke there is an area of low CBF around the infracted area (penumbra region). This area cannot be saved if tissue plasminogen activator (tPA) is administered at a CBF level of:

8 mL/100 g/min.

The nurse is caring for a client with aphasia. Which strategy will the nurse use to facilitate communication with the client?

Establishing eye contact

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?

Ischemic

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?

Psychosis, disorientation, delirium, insomnia, and hallucinations

The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient?

Semi-Fowler's

A client who's paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis?

The client uses a mirror to inspect the skin.

A patient presents to the emergency room with complaints of having an "exploding headache" for the last 2 hours. The patient is immediately seen by a triage nurse who suspects the patient is experiencing a stroke. Which of the following is a possible cause based on the characteristic symptom?

cerebral aneurysm

A physician has ordered home health and physical therapy for an older adult who will be discharged home following an acute stroke. The nurse's discharge teaching should include instructions about:

reporting specific signs and symptoms to the physician, discharge medications, and dietary concerns.

A family member comes to the clinic to talk to the nurse about a client who has had a stroke on the right side of the brain. The family member is concerned because of the deficits the client is exhibiting. The nurse knows that when a client experiences a stroke on the right side of the brain, common deficits include what? Select all that apply.

-Left-sided hemiplegia -Tendency to distractibility -Neglect of objects and people on the left side

Which interventions would be recommended for a client with dysphagia? Select all that apply

-assist the client with meals -test the gag reflex before offering food or fluids -allow ample time to eat.

A patient is in the acute phase of an ischemic stroke. How long does the nurse know that this phase may last?

1 to 3 days

Thrombolytic therapy for the treatment of an ischemic stroke should be initiated within how many hours of the onset of symptoms to obtain the best functional outcome?

3 hours

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?

4:00 p.m.

A 154-pound woman has been prescribed tPA (0.9 mg/kg) for an ischemic stroke. The nurse knows to give how many mg initially?

6.3 mg

A nurse who provides care at a community clinic is in contact with a diverse group of patients. Which of the following individuals most clearly displays risk factors for stroke?

An obese woman with a history of atrial fibrillation and type 2 diabetes

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?

Elevating the head of the bed to 30 degrees

From which direction should a nurse approach a client who is blind in the right eye?

From the left side of the client

During assessment of cognitive impairment, post-stroke, the nurse documents that the patient was experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe?

Frontal

A client undergoes cerebral angiography for evaluation after an intracranial computed tomography scan revealed a subarachnoid hemorrhage. Afterward, the nurse checks frequently for signs and symptoms of complications associated with this procedure. Which findings indicate spasm or occlusion of a cerebral vessel by a clot?

Hemiplegia, seizures, and decreased level of consciousness (LOC)

An emergency department (ED) nurse has administered an ordered bolus of tissue plasminogen activator (tPA) to a male patient who was diagnosed with stroke. During the administration of tPA, the nurse should prioritize assessments related to what problem?

Hemorrhage

A physician orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question?

Heparin sodium

Which disturbance results in loss of half of the visual field?

Homonymous hemianopsia

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?

Limited attention span and forgetfulness

The nurse is caring for a client diagnosed with a hemorrhagic stroke. The nurse recognizes that which intervention is most important?

Maintaining a patent airway

A client is admitted for evaluation of cerebral aneurysm. Which assessment finding is of greatest importance in prioritizing nursing care to this client?

Nausea

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?

Noncontrast computed tomogram

Which of the following is the initial diagnostic in suspected stroke?

Noncontrast computed tomography (CT)

When providing teaching to a client who reports tension headaches, which of the following instructions would be most beneficial to prevent onset of symptoms?

Perform stretching exercises and frequent position change.

The nurse practitioner is able to correlate a patient's neurologic deficits with the location in the brain affected by ischemia or hemorrhage. For a patient with a left hemispheric stroke, the nurse would expect to see:

Right-sided paralysis

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?

Severe exploding headache

When developing a care plan for a client who has recently suffered a stroke, a nurse includes the nursing diagnosis Risk for imbalanced body temperature. What is the rationale for this diagnosis?

The stroke may have impacted the body's thermoregulation centers.

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?

Thrombolytic therapy has a time window of only 3 hours.

A patient diagnosed with an ischemic stroke should be treated within the first 3 hours of symptom onset with which of the following?

Tissue plasminogen activator (tPA)

A patient diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for what purpose?

To prevent a stroke by removing atherosclerotic plaques blocking cerebral flow

How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tPA)?

every 15 minutes

Which of the following is accurate regarding a hemorrhagic stroke?

main presenting symptom is an "exploding headache"

A physician orders aspirin, 325 mg P.O. daily for a client who has experienced a transient ischemic attack (TIA). The nurse should teach the client that the physician has ordered this medication to:

reduce the chance of blood clot formation.

A female patient who is recovering from a stroke has begun eating a minced and pureed diet after passing the speech pathologist's swallowing assessment. This morning, the nurse set up the patient with her breakfast tray and later noticed that the woman was swallowing her food well but dribbling small amounts of food out of affected side of her mouth. How should the nurse follow up this observation?

Cue the patient to the fact that she is dribbling food while commending her for eating.

The nurse is preparing discharge teaching for a patient who is being discharged after hospitalization for a hemorrhagic stroke. What should be included in the discharge teaching for this patient?

Take antihypertensive medication as ordered.

A patient admitted with a stroke is coming to the unit from the emergency department. The nurse assigned to care for the new patient knows that what assessment finding is indicative of a stroke?

Difficulty speaking

The nurse is caring for a client with chronic migraines who is prescribed medication. What drug-related instructions should the nurse give the client?

Take medication as soon as symptoms of the migraine begin.

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?

Transient ischemic attack

A patient has been admitted to a unit at a primary stroke center after experiencing an ischemic stroke. The nurse on the unit is aware of the vital importance of rehabilitative efforts and knows that an active rehabilitation program should begin at what point?

As soon as the patient regains consciousness

Which terms refers to blindness in the right or left half of the visual field in both eyes?

Homonymous hemianopsia

A patient is exhibiting classic signs of a hemorrhagic stroke. What complaint from the patient would be an indicator of this type of stroke?

Severe stroke

An emergency department nurse is interviewing a client with signs of an ischemic stroke that began 2 hours ago. The client reports that she had a cholecystectomy 6 weeks ago and is taking digoxin, coumadin, and labetelol. This client is not eligible for thrombolytic therapy for which of the following reasons?

She is taking coumadin

The nurse is discharging home a patient who suffered a stroke. The patient has a flaccid right arm and leg and is experiencing problems with urinary incontinence. The nurse makes a referral to the home health nurse because the hospital nurse is aware that the most common patient response to a change in body image is what?

Depression