Stroke

A client is being monitored for TIAs. The client is oriented, can open the eyes spontaneously, and follows commands. What is the Glascow Coma Score?

15

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 side 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 the food on the place using the clock method. D) Place the wheelchair on the client's left side.

Place the bedside table on the right side of the bed. The client is unable to visualize to the left midline of their body. Placing the bedside table on the right side of the client's bed will permit the visualization of the items on the table.

The nurse is planning care for a client experiencing agnosia secondary to a CVA. Which collaborative intervention will be included in the plan of care? A) Observe the client swallowing for possible aspiration B) Position the client in a semi-Fowler's position when sleeping C) Place a suction setup at the client's bedside during meals D) Refer the client to an occupational therapist

Refer the client to an occupational therapist A collaborative intervention is an intervention in which another healthcare discipline - occupational therapist - is used in the care of the client.

Which client would the nurse identify as being most at risk for experiencing a CVA? A) a 55-year-old African American male B) an 85-year-old Japanese female C) a 67-year-old Caucasian male D) a 39-year-old pregnant female

a 55-year-old African American male African Americans have twice the rate of CVAs as Caucasians and men have higher incidence than women; African Americans suffer more extensive damage from a CVA than do people of other cultural groups.

Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? A) a blood glucose level of 480 mg/dL B) a right-sided carotid bruit C) a blood pressure of 220/120 mmHg D) the presence of bronchogenic carcinoma

a blood pressure of 220/120 mmHg Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a ruptured blood vessel inside the cranium.

aneurysm

a weakening or bulge in an arterial wall

penumbra region

area of low cerebral blood flow

A client has received thrombolytic treatment for an ischemic stroke. The nurse should notify the HCP if there is a rapid increase in which vital sign? A) pulse B) respiration C) blood pressure D) temperature

blood pressure

dysphagia

difficulty swallowing

What is the expected outcome of thrombolytic drug therapy for stroke? A) increased vascular permeability B) vasoconstriction C) dissolved emboli D) prevention of hemorrhage

dissolved emboli

The nurse is developing a care plan for a client who has had a stroke. The nurse asks about the client's functional status before the stroke. How will the nurse incorporate this information into the care plan? The client's functional status before the stroke will: A) guide the rehabilitation plan B) help predict outcomes C) help the client recognize physical limitations D) determine if the client can be expected to regain most functional status

guide the rehabilitation plan

The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which strategies should the nurse include in the teaching plan? (SATA) A) maintaining an upright position while eating B) restricting the diet to liquids until swallowing improves C) introducing foods on the unaffected side of the mouth D) keeping distractions to a minimum E) cutting food into large pieces of finger food

maintaining an upright position while eating introducing foods on the unaffected side of the mouth keeping distractions to a minimum

hemiplegia

paralysis of one side of the body, or part of it, d/t an injury in the motor area of the brain

What is a priority nursing assessment is the first 24 hours after admission of the client with a thrombotic stroke? A) cholesterol level B) pupil size and pupillary response C) bowel sounds D) echocardiogram

pupil size and pupillary response

dysarthria

slurred speech defects of articulation d/t neurologic causes

infarction

tissue necrosis in an area deprived of blood supply

The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? A) an oral anticoagulant medication B) a beta blocker medication C) an anti-hyperuricemic medication D) a thrombolytic medication

an oral anticoagulant medication The nurse would anticipate an oral anticoagulant , warfarin (Coumadin), to be prescribed to help prevent thrombi formation in the atria secondary to atrial fibrillation. The thrombi can become embolic and may cause TIA or stroke.

hemiparesis

weakness of one side of the body, or part of it, due to an injury in the motor area of the brain

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

Inability to recognize familiar objects This is known as agnosia.

The nurse is teaching a client about taking prophylactic warfarin sodium. Which statement indicates that the client understands how to take the drug? (SATA) A) "The drug's action peaks in 2 hours." B) "Maximum dosage is not achieved until 3-4 days after starting the medication." C) "Effects of the drug continue for 4-5 days after discontinuing the medication." D) "Protamine sulfate is the antidote for warfarin." E) "I should have my blood levels tested periodically."

"Maximum dosage is not achieved until 3-4 days after starting the medication." "Effects of the drug continue for 4-5 days after discontinuing the medication." "I should have my blood levels tested periodically."

A client with a hemorrhagic stroke is slightly agitated, heart rate is 118 bpm, respirations are 22 breaths/min, bilateral rhonchi are auscultated, SpO2 is 94%, BP is 144/88, and oral secretions are noted. What order of interventions from first to last should the nurse follow when suctioning the client to prevent ICP and maintain adequate cerebral perfusion? All options must be used. - Suction the airway - Hyperoxygenate - Suction the mouth - Provide sedation

- Provide sedation - Hyperoxygenate - Suction the airway - Suction the mouth

The client has been diagnosed with a stroke. The client's wife is concerned about her husband's generalized weakness. Which home modification should the nurse suggest to the wife prior to discharge? A) Obtain a rubber mat to place under the dinner plate B) Purchase a long-handled bath sponge for showering C) Purchase clothes with Velcro closure devices D) Obtain a raised toilet seat for the client's bathroom

Obtain a raised toilet seat for the client's bathroom Raising the toilet seat is modifying the home and addresses the client's weakness in being able to sit down and get up without straining muscles or requiring lifting assistance from the wife.

The nurse is assessing a client experiencing motor loss as a result of a left-sided CVA. Which clinical manifestations would the nurse document? A) Hemiparesis of the client's left arm and apraxia B) Paralysis of the right side of the body and ataxia C) Homonymous hemianopsia and diplopia D) Impulsive behavior and hostility toward family

Paralysis of the right side of the body and ataxia Most common motor dysfunction of a CVA is paralysis of one side of the body, hemiplegia; in this case with a left-sided CVA, the paralysis would affect the right side. Ataxia is impaired ability to coordinate movement.

A 78-year-old client is admitted to the ED with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority? A) Prepare to administer recombinant tissue plasminogen activator (t-PA) B) Discuss the precipitating factors that caused the symptoms C) Schedule for a STAT CT scan of the head D) Notify the speech pathologist for an emergency consult

Schedule for a STAT CT scan of the head A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. If CVA is diagnosed, the CT scan can determine if it is a hemorrhagic or ischemic accident and guide treatment.

hemianopsia

blindness in one half of the visual field of one or both eyes

Which outcomes indicate effective management of a conscious client who is being treated with recombinant tissue plasminogen therapy during the initial phase of an ischemic stroke? (SATA) A) headache reduced B) dysphagia improved C) visual disturbances improved D) responds to comfort measures E) no signs or symptoms of bleeding

headache reduced responds to comfort measures no signs or symptoms of bleeding A headache is commonly associated with an ischemic stroke. A conscious client responds to comfort measures. Bleeding is a side effect of tPA therapy to dissolve the clots; absence of bleeding is a desired outcome.

receptive aphasia

inability to understand what someone else is saying; often associated with damage to the temporal lobe area

A client admitted with possible ischemic stroke has been aphasic for 3 hours and has a blood pressure of 220/120 mmHg. Which prescription by the HCP should the nurse question? A) labetalol drip to keep the BP <120/80 mmHg B) tissue plasminogen activator (tPA) per protocol C) normal saline IV at 75 mL/hr D) bed elevated 30 degrees

labetalol drip to keep the BP <120/80 mmHg When a client has a stroke, autoregulation is a protective mechanism used to protect the brain. An elevated BP helps to increase cerebral perfusion. The standard of care is to administer tPA within 4.5 hours of signs and symptoms of a stroke.

agnosia

loss of ability to recognize objects through a particular sensory system may be visual, auditory, tactile

The nurse is planning the care for a hemiplegic client to prevent joint deformities of the arm and hand. Which position is appropriate? (SATA) A) placing a pillow in the axilla so the arm is away from the body B) inserting a pillow under the slightly flexed arm so the hand is higher than the elbow C) immobilizing the extremity in a sling D) positioning a hand cone in the hand so the fingers are barely flexed E) keeping the arm at the side using a pillow

placing a pillow in the axilla so the arm is away from the body inserting a pillow under the slightly flexed arm so the hand is higher than the elbow positioning a hand cone in the hand so the fingers are barely flexed

The nurse is observing the UAP give mouth care to a client who has had a stroke and is unconscious. The nurse should intervene if the UAP does which? A) positions the client on the back with a small pillow under the head B) keeps portable suctioning equipment at the bedside C) opens the client's mouth with a padded tongue blade D) cleans the client's mouth and teeth with a toothbrush

positions the client on the back with a small pillow under the head

Which positioning technique is most effective when there is only one person to assist the client to move from the left side to the right side if the client has hemiparalysis? A) rolling the client onto the side B) sliding the client to move up in the bed C) lifting the client when moving the client up in bed D) having the client help lift off the bed using a trapeze

rolling the client onto the side

apraxia

inability to perform previously learned motor acts on a voluntary basis

aphasia

inability to express oneself or to understand language

expressive aphasia

inability to express oneself; often associated with damage to the left frontal lobe area

The nurse is caring for a client who is paraplegic as the result of a stroke. At home, the client uses a wheelchair for mobility and can transfer independently. The client is now being treated with IV antibiotics for a sacral wound with a peripherally inserted central catheter. The client is alert and oriented and has no previous history of falling. Using the Morse Fall Scale, what is the client's total score?

35

A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the ICU nurse implement? A) Administer a stool softener BID B) Encourage the client to cough hourly C) Monitor neurological status every shift D) Maintain the dopamine drip to keep BP at 160/90

Administer a stool softener BID The client is at risk for increased intracranial pressure whenever performing the Valsalva maneuver, which will occur when straining during defecation. Therefore, stool softeners would be appropriate.

The 85-year-old client diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first? A) Administer a nonnarcotic analgesic B) Prepare for STAT MRI C) Start an IV infusion with D5W at 100 mL/hr D) Complete a neurological assessment

Complete a neurological assessment The nurse must complete a neurological assessment to help determine the cause of the headache before taking any further action.

The nurse is assessing the adaptation of a client to changes in functional status after a stroke. Which observation indicates to the nurse that the client is adapting most successfully? A) Gets angry with family if they interrupt a task B) Experiences bouts of depression and irritability C) Has difficulty with using modified feeding utensils D) Consistently uses adaptive equipment in dressing self

Consistently uses adaptive equipment in dressing self Clients are evaluated as coping successfully with lifestyle changes after a stroke if they make appropriate lifestyle alterations, use the assistance of others, and have appropriate social interactions.

The nurse is assisting a client with a stroke who has homonymous hemianopsia. The nurse should understand that the client will do which when eating? A) Have a preference for foods high in salt B) Eat food on only half of the plate C) Forget the names of foods D) Be unable to swallow liquids

Eat food on only half of the plate

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? (SATA) A) Have suction equipment available for use B) Feed the client thickened liquids C) Place the food on the unaffected side of the mouth D) Assign an assistive personnel to feed the client slowly E) Teach the client to swallow with the neck flexed

Have suction equipment available for use Feed the client thickened liquids Place the food on the unaffected side of the mouth Teach the client to swallow with the neck flexed Suction should be available in case of choking and aspiration. Liquids should be thicker than water to prevent aspiration. Placing food on unaffected side of mouth allows them to have better control of the food and reduces risk of aspiration. Client should be taught to flex the neck - tucking the chin down and under the epiglottis during swallowing.

Which is the most effective means of preventing plantar flexion in a client who has had a stroke with residual paralysis? A) Place the client's feet against a firm footboard B) Reposition the client every 2 hours C) Have the client wear ankle-high tennis shoes at intervals throughout the day D) Massage the client's feet and ankles regularly

Have the client wear ankle-high tennis shoes at intervals throughout the day

A client arrives in the ED with an ischemic stroke. What should the nurse to before the client receives tPA? A) Ask what medications the client is taking B) Complete a history and health assessment C) Identify the time of onset of the stroke D) Determine if the client is scheduled for any surgical procedures

Identify the time of onset of the stroke

A nurse is caring for a client who has experienced a right-hemispheric stroke. The nurse should expect the client to have difficulty with which of the following? (SATA) A. Impulse control B. Moving the left side C. Depth perception D. Speaking E. Situational awareness

Impulse control Moving the left side Depth perception Situational awareness A client who has experienced a right-hemispheric stroke can exhibit impulse control (urgency to use restroom), left-sided hemiplegia, loss of depth perception, and can demonstrate a lack of awareness of surroundings.

Following a stroke, a client has dysphagia and left-sided facial paralysis. Which feeding technique will be the most helpful at this time? A) Encourage sipping diluted liquid meal supplements from a straw B) Position the client with the bed at a 30-degree angle C) Offer solid foods from the unaffected side of the mouth D) Feed the client a soft diet from a spoon into the left side of the mouth

Offer solid foods from the unaffected side of the mouth

A nurse is teaching a client who had a stroke about ways to adapt to a visual disability. Which does the nurse identify as the primary safety precaution to use? A) Wear a patch over one eye B) Place personal items on the sighted side C) Lie in bed with the unaffected side toward the door D) Turn the head from side to side when walking

Place personal items on the sighted side

The client diagnosed with a right-sided CVA is admitted to the rehab unit. Which interventions should be included in the nursing care plan? (SATA) A) Position the client prevent shoulder adduction B) Turn and reposition the client every shift C) Encourage the client to move the affected side D) Perform quadriceps exercises 3 times a day E) Instruct the client to hold the fingers in a fist

Position the client prevent shoulder adduction Encourage the client to move the affected side Placing a small pillow under the shoulder will prevent the shoulder from adducting toward the chest and developing a contracture. The client should not ignore the paralyzed side, and the nurse must encourage the client to move it as much as possible; a written schedule may assist the client in exercising.

The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the plan of care? A) Potential for injury B) Powerlessness C) Disturbed thought processes D) Sexual dysfunction

Powerlessness Expressive aphasia means that the client cannot communicate thoughts but understanding what is being communicated; this leads to frustration, anger, depression, and the inability to verbalize needs, which, in turn, causes the client to have a lack of control and feel powerless.

When communicating with a client who has aphasia, which approaches are helpful? (SATA) A) Present one thought at a time B) Avoid writing messages C) Speak at normal volumes D) Make use of gestures E) Encourage pointing to the needed object

Present one thought at a time Speak at normal volumes Make use of gestures Encourage pointing to the needed object

A nurse is caring for a client who has global aphasia (both receptive and expressive). Which of the following should the nurse include in the client's plan of care? (SATA) 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

Speak to the client at a slower rate Assist the client to use cards with pictures Give instructions one step at a time Clients with global aphasia have difficulty with speaking and understanding speech. Strategies that will enhance understanding is to speak slower, use alternative forms of communication, and give instructions one step at a time.

A client is experiencing mood swings after a stroke and often has episodes of tearfulness that are distressing to the family. Which is the best technique for the nurse to instruct family members to try when the client experiences a crying episode? A) Sit quietly with the client until the episode is over B) Ignore the behavior C) Attempt to divert the client's behavior D) Tell the client that the behavior is unacceptable

Tell the client that the behavior is unacceptable

The nurse and an UAP are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? A) The assistant places a gait belt around the client's waist prior to ambulating B) The assistant places the client on the back with the client's head to the side C) The assistant places a hand under the client's right axilla to move up in bed D) The assistant praises the client for attempting to perform ADLs independently

The assistant places a hand under the client's right axilla to move up in bed This action is inappropriate and would require intervention by the nurse because pulling on a flaccid shoulder joint could cause shoulder dislocation; the client should be pulled up by placing the arm underneath the back or using a lift sheet.

The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? (SATA) A) The client is aphasic B) The client has weakness on the right side of the body C) The client has complete bilateral paralysis of the arms/legs D) The client has weakness on the right side of face/tongue E) The client has lost the ability to move the right arm but is able to walk independently F) The client has lost the ability to ambulate independently but is able to feed and bathe without assistance

The client is aphasic The client has weakness on the right side of the body The client has weakness on the right side of face/tongue Hemiparesis is a weakness of one side of the body that may occur after stroke. It involves weakness of face, tongue, arm, and leg on one side. These clients are also aphasic, unable to discriminate words and letters.

The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures use when caring for the client? A) We need to discourage him from wearing eyeglasses B) We need to place objects in his impaired field of vision C) We need to approach him from the impaired field of vision D) We need to remind him to turn his head to scan the lost visual field

We need to remind him to turn his head to scan the lost visual field Homonymous hemianopsia is loss of half of the visual field. This client should have objects placed in the intact field of vision, and the nurse should approach the client from the intact side. The nurse should educate client to scan their environment to overcome the visual deficit.

For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication? A) speaking loudly and slowly B) using a "picture board" for the client to point to pictures C) writing instructions so the client can read them D) speaking in short sentences

using a "picture board" for the client to point to pictures