Neuro. Chapter 38

A client is prescribed sumatriptan for the treatment of migraine headache. Which client statement would indicate a need for additional teaching from the nurse?

"I use this to prevent migraines."

A client who has experienced an initial transient ischemic attack (TIA) states: "I'm glad it wasn't anything serious." Which is the best nursing response to this statement?

"TIA is a warning sign. Let's talk about lowering your risks."

The client with a cerebral aneurysm asks the nurse, "What's the big fuss over a headache?" Which is the best response from the nurse regarding to a cerebral aneurysm?

"Your physician wants to evaluate the location and condition of the aneurysm."

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?

Absolute bed rest in a quiet, nonstimulating environment

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

A client has experienced a transient ischemic attack (TIA) and presents with carotid bruits. Which is the priority action to be taken by the nurse, following a bilateral carotid endarterectomy?

Anticipate need for endotracheal intubation.

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?

Anticoagulant therapy

A client has just been diagnosed with a cerebral aneurysm. In planning discharge teaching for this client, what instructions should be delivered by the nurse to the client?

Avoid heavy lifting.

A client is brought to the emergency department with symptoms of a cerebrovascular accident (CVA). The nurse would anticipate which diagnostic evaluation to be completed prior to initiation of treatment?

Brain CT scan or MRI

The nurse is providing diet-related advice to a client who experienced a cerebrovascular accident (CVA) and is now having difficulty swallowing. Which food choices should the nurse suggest to the client to reduce the potential for aspiration? Select all that apply.

Choose thickened commercial beverages. Choose foods that are cold.

While the nurse is making initial rounds after coming on shift, you find a client thrashing about in bed complaining of a severe headache. The client tells the nurse the pain is behind the right eye, which is red and tearing. What type of headache would the nurse suspect this client of having?

Cluster

An elderly client, who has fallen several times at home, is admitted for possible transient ischemic attack (TIA). Which assessment finding is most significant in determining care for this client?

Drooling from side of mouth

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?

Elevation of the head of the bed

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

From the left side of the client

A client is brought into the emergency department with a diagnosis of ruptured cerebral aneurysm. Which assessment data provides the most important information in preparing for the nursing care of this client?

Grade V on the Hunt-Hess Scale

A client who had a cerebrovascular accident has dysphagia related to hemiplegia and has a history of aspiration. Which nursing interventions would be contraindicated for this client?

Have the client tilt their head back to facilitate swallowing.

Which is the most common motor dysfunction seen in clients diagnosed with stroke?

Hemiplegia

A client diagnosed with migraine headaches asks the nurse what he can do to help control the headaches and minimize the number of attacks he is having. What instructions should the nurse give this client?

Identify and avoid factors that precipitate or intensify an attack.

A diagnostic test has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include honey thickened liquids. Which of the following is the priority nursing diagnosis for this client?

Impaired Swallowing

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?

Left-sided cerebrovascular accident (CVA)

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?

Migraines often coincide with menstrual cycle.

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 client with a cerebrovascular accident (CVA) is having difficulty with eating food on the plate. Which is the best priority nursing action to be taken?

Perform a vision field assessment.

A client has tension headaches. The nurse recommends massage as a treatment for tension headaches. How does massage help clients with tension headaches? Relaxes muscles

Relaxes muscles

Which nursing assessment finding is most indicative of a hemorrhagic stroke?

Sudden onset of breathing alterations

Which of the following psychotropic drug classifications is often prescribed for neuropathic pain?

Tricyclic antidepressants

A client reports light-headedness, speech disturbance, and left-sided weakness lasting for several hours. The neurologist diagnosed a transient ischemic attack, which caused the client great concern. What would the nurse include during client education?

When symptoms cease, the client will return to presymptomatic state.

Which signs and symptoms would the nurse expect to see in a client who has had a large cerebral hemorrhage?

breathing is noisy and labored, cheek on the side of the CVA blows out on exhalation, eyes deviate toward the affected side of the brain

A nurse is providing care to a client who has had a stroke. Which symptoms are consistent with right-sided stroke?

impulsive behavior, poor judgment, deficits in left visual fields

A nurse is administering intravenous tissue plasminogen activator (tPA) to a client having a stroke. Which criteria must be met before administering the agent? Select all that apply.

onset of stroke within 3 hours of initiation of therapy normal prothrombin (PT) and partial thromboplastin (PTT) times

A rehabilitation nurse caring for a client who has had a stroke is approached by the client's family and asked why the client has to do so much for herself when she is obviously struggling. What would be the nurse's best answer?

"The focus on care in a rehabilitation facility is to help the client to resume as much self-care as possible."

A 76-year-old male client is brought to the clinic by his daughter. The daughter states that her father has had two transient ischemic attacks (TIAs) in the past week. The physician orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option does the nurse expect the physician to offer this client to increase blood flow to the brain? Select all that apply.

Balloon angioplasty of the carotid artery followed by stent placement Carotid endarterectomy

A nurse is explaining the pathophysiology of stroke to a client and family. Place in correct order from first to last the steps in the process of stroke, which the nurse would review.

Oxygen is depleted. Glutamate is released. Glutamate activates NMDA receptors and overexcites brain cells. Toxic free radicals are released. Toxic free radicals destroy cells.

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 is caring for a client with dysphagia. Which intervention would be contraindicated while caring for this client?

Placing food on the affected side of the mouth

A client is being assessed for a possible transient ischemic attack (TIA). Which of the following assessment findings suggests to the nurse that the client is experiencing a TIA?

Impaired muscle coordination

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

A client presents to the walk-in clinic complaining of a migraine. The client is prescribed an antileptic. What should the nurse suggest to the client?

Use caution while driving or performing hazardous activities.

A client has a 12-year history of migraine headaches and is frustrated over how these headaches impact lifestyle. The nurse discusses the potential triggers of the client's migraines. Which is not a potential trigger to migraines?

seasonal changes

Medical management of a client with a cerebral aneurysm does not include:

thrombolytic therapy.