Prep-U for exam 2
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?
"Emotional lability is common after a stroke, and it usually improves with time."
The nurse understands the urgency of timely intervention for an ischemic stroke. Based on her knowledge of cerebral blood flow (normal CBF = 50 to 55 mL/100 g/min) and obstruction, she is aware that neurons will no longer maintain aerobic respiration at which level of CBF?
15 to 20 mL/100 g/min
A nurse knows that, for a patient with an ischemic stroke, tPA is contraindicated if the blood pressure reading is:
190 mm Hg/120 mm Hg
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
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 caring for a client with aphasia. Which strategy will the nurse use to facilitate communication with the client?
Establishing eye contact
When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke?
The day the patient has the stroke
A woman has been brought to the emergency department (ED) by her distraught husband who believes that she has had a stroke. A rapid assessment by the care team confirms that the husband's suspicions are likely accurate, and the woman is being screened for the possible administration of recombinant tissue plasminogen activator (r tPA). Which of the following factors would contraindicate the use of tPA?
The woman's stroke has a hemorrhagic etiology.
Which of the following is the chief cause of intracerebral hemorrhage (ICH)?
Uncontrolled hypertension
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?
Weakness on one side of the body and difficulty with speech
Which term will the nurse use when referring to blindness in the right or left half of the visual field in both eyes?
Homonymous hemianopsia
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
aspirin.
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 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 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?
Lack of deep tendon reflexes
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 suspected of having had a stroke. Which is the initial diagnostic test for a stroke?
Noncontrast computed tomography
A male patient with cerebrovascular accident (CVA) is prescribed medication to treat the disorder. The patient wants to know what other measures may help reduce CVA. Which of the following is an accurate suggestion for the patient?
Reduce hypertension and high blood cholesterol levels.
While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are:
Severe headache and early change in level of consciousness
Which is a modifiable risk factor for transient ischemic attacks and ischemic strokes?
Smoking
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?
cardio embolic