prepu management of pts with cerebrovascular disorders
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: a 28 y/o pregnant african american woman b: a 62 y/o caucasian woman c: a 60 y/o african american man d: a 40 y/o caucasian woman
a 60 y/o african american man
Which of the following statements reflects nursing management of the patient with expressive aphasia? a: Speak slowly and clearly to assist the patient in forming the sounds. b: Speak clearly and in simple sentences; use gestures or pictures when able. c: Encourage the patient to repeat sounds of the alphabet. d: Frequently reorient the patient to time, place, and situation
encourage the pt to repeat sounds of the alphabet
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: "This behavior is common in clients with stroke. Which does your spouse do more often? Laugh or cry?" c: "You sound stressed; maybe using some stress management techniques will help." d: "You seem upset, and it may be hard for you to focus on the teaching, I'll come back later."
emotional lability is common after a stroke, and it usually improves with time
A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? a: methyldopa b: phenytoin c: heparin sodium d: dexamethasone
heparin sodium
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: Expressive aphasia d: Neglect of the right side
neglect of the left side
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: Left-sided cerebrovascular accident (CVA) b: Right-sided cerebrovascular accident (CVA) c: Transient ischemic attack (TIA) d: Completed Stroke
left-sided CVA
The geriatric advanced practice nurse (APN) is doing client teaching with a client who has had a cerebrovascular accident (CVA) and the client's family. One concern the APN addresses is a potential for falls related to the CVA and resulting muscle weakness. What would be most important for the APN to include in teaching related to this concern? a: Need for support group due to decreased self image related to restricted mobility. b: Use of tripod cane. c:Leg exercises to strengthen muscle weakness. d: Remove throw rugs and electrical cords from home environment.
remove throw rugs and electrical cords from home environment
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: intracranial pressure is increased by a space-occupying bleed b: thrombolytic therapy has a time window of only 3 hours c: a ruptured intracranial aneurysm must quickly be repaired d: a ruptured arteriovenous malformation will cause deficits until it is stopped
thrombolytic therapy has a time window of only 3 hours
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: surgery 6 weeks ago b: international normalized ratio greater than 2 c: two hour time period of the stroke d: taking digoxin
international normalized ratio greater than 2
While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are: a: confusion or change in mental status b: foot drop and external hip rotation c: weakness on one side of the body and difficulty with speech d: severe headache and early change in level of consciousness
severe headache and early change in level of consciousness