Stroke Practice Questions (Test #3, Fall 2020)
Which client would the nurse identify as being most at risk for experiencing a cerebrovascular accident (CVA)? 1. A 55-year-old African American male. 2. An 84-year-old Japanese female. 3. A 67-year-old Caucasian male. 4. A 39-year-old pregnant female.
1 1. African Americans have twice the rate of CVAs as Caucasians and men have a higher incidence than women; African Americans also suffer more extensive damage from a CVA than do people of other cultural groups. 2. Females are less likely to have a CVA than males, but advanced age does increase the risk for CVA. The Asian population has a lower risk, possibly as a result of their relatively high intake of omega-3 fatty acids, antioxidants found in fish. 3. Caucasians have a lower risk of CVA than do African Americans, Hispanics, and Native Pacific Islanders. 4. Pregnancy is a minimal risk for having a CVA. TEST TAKING HINT: Note the age of the client if this information is given, but take this information in context with the additional information provided in the answer options. The 84-year-old may appear to be the best answer but not if the client is a female and Asian, which rules out this option for the client most at risk
A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement? 1. Administer a stool softener bid. 2. Encourage the client to cough hourly. 3. Monitor neurological status every shift. 4. Maintain the dopamine drip to keep BP at 160/90.
1 1. 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. 2. Coughing increases intracranial pressure and is discouraged for any client who has had a craniotomy. The client is encouraged to turn and breathe deeply but not to cough. 3. Monitoring the neurological status is appropriate for this client, but it should be done much more frequently than every shift. 4. Dopamine is used to increase blood pressure or to maintain renal perfusion, and a BP of 160/90 is too high for this client. TEST TAKING HINT: The test taker should always notice if an answer option has a time frame—every shift, every four (4) hours, or daily. Whether or not the time frame is correct may lead the test taker to the correct answer.
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? 1. An oral anticoagulant medication. 2. A beta blocker medication. 3. An anti-hyperuricemic medication. 4. A thrombolytic medication.
1 1. 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 a TIA or CVA (stroke). 2. Beta blockers slow the heart rate and decrease blood pressure but would not be an anticipated medication to help prevent a TIA secondary to atrial fibrillation. 3. An anti-hyperuricemic medication is administered for a client experiencing gout and decreases the formation of tophi. 4. A thrombolytic medication is administered to dissolve a clot, and it may be ordered during the initial presentation for a client with a CVA but not on discharge. TEST TAKING HINT: In the stem of this question, there are two disease processes mentioned—atrial fibrillation and TIA. The reader must determine how one process affects the other before answering the question. In this question, the test taker must know atrial fibrillation predisposes the client to the formation of thrombi, and, therefore, the nurse should anticipate the health-care provider ordering a medication to prevent clot formation, an anticoagulant.
Which of the following nursing measures is not appropriate when providing oral hygiene for a client who has had a stroke? 1.Placing the client on the back with a small pillow under the head. 2.Keeping portable suctioning equipment at the bedside. 3.Opening the client's mouth with a padded tongue blade. 4.Cleaning the client's mouth and teeth with a toothbrush.
1 A helpless client should be positioned on the side, not on the back, with the head on a small pillow. A lateral position helps secretions escape from the throat and mouth, minimizing the risk of aspiration. It may be necessary to suction the client if he aspirates. Suction equipment should be nearby. It is safe to use a padded tongue blade, and the client should receive oral care, including brushing with a toothbrush.
In planning care for the client who has had a stroke, the nurse should obtain a history of the client's functional status before the stroke because: 1.The rehabilitation plan will be guided by it. 2.Functional status before the stroke will help predict outcomes. 3.It will help the client recognize physical limitations. 4.The client can be expected to regain most functional status.
1 The primary reason for the nursing assessment of a client's functional status before and after a stroke is to guide the plan. The assessment does not help to predict how far the rehabilitation team can help the client to recover from the residual effects of the stroke, only what plans can help a client who has moved from one functional level to another. The nursing assessment of the client's functional status is not a motivating factor
The nurse is planning the care of a hemiplegic client to prevent joint deformities of the arm and hand. Which of the following positions are appropriate? Select all that apply: 1.Placing a pillow in the axilla so the arm is away from the body. 2.Inserting a pillow under the slightly flexed arm so the hand is higher than the elbow. 3.Immobilizing the extremity in a sling. 4.Positioning a hand cone in the hand so the fingers are barely flexed. 5.Keeping the arm at the side using a pillow.
1,2,4 Placing a pillow in the axilla so the arm is away from the body keeps the arm abducted and prevents skin from touching skin to avoid skin breakdown. Placing a pillow under the slightly flexed arm so the hand is higher than the elbow prevents dependent edema. Positioning a hand cone (not a rolled washcloth) in the hand prevents hand contractures. Immobilization of the extremity may cause a painful shoulder-hand syndrome. Flexion contractures of the hand, wrist, and elbow can result from immobility of the weak or paralyzed extremity. It is better to extend the arms to prevent contractures.
The client diagnosed with a right-sided cerebrovascular accident is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply. 1. Position the client to prevent shoulder adduction. 2. Turn and reposition the client every shift. 3. Encourage the client to move the affected side. 4. Perform quadriceps exercises three (3) times a day. 5. Instruct the client to hold the fingers in a fist.
1,3 1. Placing a small pillow under the shoulder will prevent the shoulder from adducting toward the chest and developing a contracture. 2. The client should be repositioned at least every two (2) hours to prevent contractures, pneumonia, skin breakdown, and other complications of immobility. 3. 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. 4. These exercises are recommended, but they must be done at least five (5) times a day for 10 minutes to help strengthen the muscles for walking. 5. The fingers are positioned so that they are barely flexed to help prevent contracture of the hand. TEST TAKING HINT: Be sure to look at the intervals of time for any intervention; note that "every shift" and "three (3) times a day" are not appropriate time intervals for this client. Because this is a "select all that apply" question, the test taker must read each answer option and decide if it is correct; one will not eliminate another
The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which of the following strategies should the nurse include in the teaching plan. Check all that apply. 1.Maintaining an upright position while eating. 2.Restricting the diet to liquids until swallowing improves. 3.Introducing foods on the unaffected side of the mouth. 4.Keeping distractions to a minimum. 5.Cutting food into large pieces of finger food.
1,3,4 A client with dysphagia (difficulty swallowing) commonly has the most difficulty ingesting thin liquids, which are easily aspirated. Liquids should be thickened to avoid aspiration. Maintaining an upright position while eating is appropriate because it minimizes the risk of aspiration. Introducing foods on the unaffected side allows the client to have better control over the food bolus. The client should concentrate on chewing and swallowing; therefore, distractions should be avoided. Large pieces of food could cause choking; the food should be cut into bite-sized pieces
When communicating with a client who has aphasia, which of the following are helpful? Select all that apply. 1.Present one thought at a time. 2.Avoid writing messages. 3.Speak with normal volume. 4.Make use of gestures. 5.Encourage pointing to the needed object.
1,3,4,5 The goal of communicating with a client with aphasia is to minimize frustration and exhaustion. The nurse should encourage the client to write messages or use alternative forms of communication to avoid frustration. Presenting one thought at a time decreases stimuli that may distract the client, as does speaking in a normal volume and tone. The nurse should ask the client to point to objects and encourage the use of gestures to assist in communicating
The nurse is assessing a client experiencing motor loss as a result of a left-sided cerebrovascular accident (CVA). Which clinical manifestation would the nurse document? 1. Hemiparesis of the client's left arm and apraxia. 2. Paralysis of the right side of the body and ataxia. 3. Homonymous hemianopsia and diplopia. 4. Impulsive behavior and hostility toward family
2 1. A left-sided cerebrovascular accident (CVA) will result in right-sided motor deficits; hemiparesis is weakness of one-half of the body, not just the upper extremity. Apraxia, the inability to perform a previously learned task, is a communication loss, not a motor loss. 2. The 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 an impaired ability to coordinate movement. 3. Homonymous hemianopsia (loss of half of the visual field of each eye) and diplopia (double vision) are visual field deficits that a client with a CVA may experience, but they are not motor losses. 4. Personality disorders occur in clients with a right-sided CVA and are cognitive deficits; hostility is an emotional deficit. TEST TAKING HINT: Be sure to always notice adjectives describing something. In this case, "left-sided" describes the type of CVA. Also be sure to identify exactly what the question is asking—in this case, about "motor loss," which will help rule out many of the possible answer options.
The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the plan of care? 1. Potential for injury. 2. Powerlessness. 3. Disturbed thought processes. 4. Sexual dysfunction.
2 1. Potential for injury is a physiological, not a psychosocial, problem. 2. Expressive aphasia means that the client cannot communicate thoughts but understands 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. 3. A disturbance in thought processes is a cognitive problem; with expressive aphasia the client's thought processes are intact. 4. Sexual dysfunction can have a psychosocial or physical component, but it is not related to expressive aphasia. TEST TAKING HINT: The test taker should always make sure that the choice selected as the correct answer matches what the question is asking. The stem has the adjective "psychosocial," so the correct answer must address psychosocial needs.
For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication? 1.Speaking loudly and slowly. 2.Using a "picture board" for the client to point to pictures. 3.Writing directions so client can read them. 4.Speaking in short sentences.
2 Expressive aphasia is a condition in which the client understands what is heard or written but cannot say what he or she wants to say. A communication or picture board helps the client communicate with others in that the client can point to objects or activities that he or she desires
The nurse is assisting a client with a stroke who has homonymous hemianopia. The nurse should understand that the client will: 1.Have a preference for foods high in salt. 2.Eat food on only half of the plate. 3.Forget the names of foods. 4.Not be able to swallow liquids."
2 Homonymous hemianopia is blindness in half of the visual field; therefore, the client would see only half of the plate. Eating only the food on half of the plate results from an inability to coordinate visual images and spatial relationships. There may be an increased preference for foods high in salt after a stroke, but this would not be related to homonymous hemianopia. Forgetting the names of foods is a sign of aphasia, which involves a cerebral cortex lesion. Being unable to swallow liquids is dysphagia, which involves motor pathways of cranial nerves IX and X, including the lower brain stem.
What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? 1.Cholesterol level. 2.Pupil size and pupillary response. 3.Bowel sounds. 4.Echocardiogram.
2 It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves. The cholesterol level is not a priority assessment, although it may be an assessment to be addressed for long-term healthy lifestyle rehabilitation. Bowel sounds need to be assessed because an ileus or constipation can develop, but this is not a priority in the first 24 hours, when the primary concerns are cerebral hemorrhage and increased intracranial pressure. An echocardiogram is not needed for the client with a thrombotic stroke without heart problems.
Which of the following techniques is not appropriate when the nurse changes a client's position in bed if the client has hemiparalysis? 1.Rolling the client onto the side. 2.Sliding the client to move up in bed. 3.Lifting the client when moving the client up in bed. 4.Having the client help lift off the bed using a trapeze.
2 Sliding a client on a sheet causes friction and is to be avoided. Friction injures skin and predisposes to pressure ulcer formation. Rolling the client is an acceptable method to use when changing positions as long as the client is maintained in anatomically neutral positions and the limbs are properly supported. The client may be lifted as long as the nurse has assistance and uses proper body mechanics to avoid injury to himself or herself or the client. Having the client help lift off the bed with a trapeze is an acceptable means to move a client without causing friction burns or skin breakdown
The nurse is teaching a client about taking prophylactic warfarin sodium (Coumadin). Which statement indicates that the client understands how to take the drug? Select all that apply. 1."The drug's action peaks in 2 hours." 2."Maximum dosage is not achieved until 3 to 4 days after starting the medication." 3."Effects of the drug continue for 4 to 5 days after discontinuing the medication." 4."Protamine sulfate is the antidote for warfarin." 5."I should have my blood levels tested periodically."
2, 3, 5 The maximum dosage of warfarin sodium (Coumadin) is not achieved until 3 to 4 days after starting the medication, and the effects of the drug continue for 4 to 5 days after discontinuing the medication. The client should have blood levels tested periodically to make sure that the desired level is maintained. Warfarin has a peak action of 9 hours. Vitamin K is the antidote for warfarin; protamine sulfate is the antidote for heparin.
The nurse and an unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? 1. The assistant places a gait belt around the client's waist prior to ambulating. 2. The assistant places the client on the back with the client's head to the side. 3. The assistant places a hand under the client's right axilla to move up in bed. 4. The assistant praises the client for attempting to perform ADLs independently
3 1. Placing a gait belt prior to ambulating is an appropriate action for safety and would not require the nurse to intervene. 2. Placing the client in a supine position with the head turned to the side is not a problem position, so the nurse does not need to intervene. 3. 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. 4. The client should be encouraged and praised for attempting to perform any activities independently, such as combing hair or brushing teeth. TEST TAKING HINT: This type of question has three answer options that do not require a nurse to intervene to correct a subordinate. Remember to read every possible answer option before deciding on a correct one.
A 78-year-old client is admitted to the emergency department (ED) with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority? 1. Prepare to administer recombinant tissue plasminogen activator (rt-PA). 2. Discuss the precipitating factors that caused the symptoms. 3. Schedule for a STAT computed tomography (CT) scan of the head. 4. Notify the speech pathologist for an emergency consult.
3 1. The drug rt-PA may be administered, but a cerebrovascular accident (CVA) must be verified by diagnostic tests prior to administering it. The drug rt-PA helps dissolve a blood clot, and it may be administered if an ischemic CVA is verified; rt-PA is not given if the client is experiencing a hemorrhagic stroke. 2. Teaching is important to help prevent another CVA, but it is not the priority intervention on admission to the emergency department. Slurred speech indicates problems that may interfere with teaching. 3. A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. If a CVA is diagnosed, the CT scan can determine if it is a hemorrhagic or an ischemic accident and guide treatment. 4. The client may be referred for speech deficits and/or swallowing difficulty, but referrals are not the priority in the emergency department. TEST TAKING HINT: When "priority" is used in the stem, all answer options may be appropriate for the client situation, but only one option is the priority. The client must have a documented diagnosis before treatment is started
Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? 1. A blood glucose level of 480 mg/dL. 2. A right-sided carotid bruit. 3. A blood pressure (BP) of 220/120 mm Hg. 4. The presence of bronchogenic carcinoma
3 1. This glucose level is elevated and could predispose the client to ischemic neurological changes due to blood viscosity, but it is not a risk factor for a hemorrhagic stroke. 2. A carotid bruit predisposes the client to an embolic or ischemic stroke but not to a hemorrhagic stroke. 3. Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a ruptured blood vessel inside the cranium. 4. Cancer is not a precursor to developing a hemorrhagic stroke. TEST TAKING HINT: Both options "1" and "2" are risk factors for an ischemic or embolic type of stroke. Knowing this, the test taker can rule out these options as incorrect.
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? 1.Sit quietly with the client until the episode is over. 2.Ignore the behavior. 3.Attempt to divert the client's attention. 4.Tell the client that this behavior is unacceptable."
3 A client who has brain damage may be emotionally labile and may cry or laugh for no explainable reason. Crying is best dealt with by attempting to divert the client's attention. Ignoring the behavior will not affect the mood swing or the crying and may increase the client's sense of isolation. Telling the client to stop is inappropriate
During the first 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal is to control the client's: 1.Pulse. 2.Respirations. 3.Blood pressure. 4.Temperature.
3 Control of blood pressure is critical during the first 24 hours after treatment because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy. Vital signs are monitored, and blood pressure is maintained as identified by the physician and specific to the client's ischemic tissue needs and risk of bleeding from treatment. The other vital signs are important, but the priority is to monitor blood pressure.
A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. The nurse should first: 1.Ask what medications the client is taking. 2.Complete a history and health assessment. 3.Identify the time of onset of the stroke. 4.Determine if the client is scheduled for any surgical procedures.
3 Studies show that clients who receive recombinant t-PA treatment within 3 hours after the onset of a stroke have better outcomes. The time from the onset of a stroke to t-PA treatment is critical. A complete health assessment and history is not possible when a client is receiving emergency care. Upcoming surgical procedures may need to be delayed because of the administration of t-PA, which is a priority in the immediate treatment of the current stroke. While the nurse should identify which medications the client is taking, it is more important to know the time of the onset of the stroke to determine the course of action for administering t-PA
Which of the following is the most effective means of preventing plantar flexion in a client who has had a stroke with residual paralysis? 1.Place the client's feet against a firm footboard. 2.Reposition the client every 2 hours. 3.Have the client wear ankle-high tennis shoes at intervals throughout the day. 4.Massage the client's feet and ankles regularly.
3 The use of ankle-high tennis shoes has been found to be most effective in preventing plantar flexion (footdrop) because they add support to the foot and keep it in the correct anatomic position. Footboards stimulate spasms and are not routinely recommended. Regular repositioning and range-of-motion exercises are important interventions, but the client's foot needs to be in the correct anatomic position to prevent overextension of the muscle and tendon. Massaging does not prevent plantar flexion and, if rigorous, could release emboli
What is the expected outcome of thrombolytic drug therapy for stroke? 1.Increased vascular permeability. 2.Vasoconstriction. 3.Dissolved emboli. 4.Prevention of hemorrhage
3 Thrombolytic enzyme agents are used for clients with a thrombotic stroke to dissolve emboli, thus reestablishing cerebral perfusion. They do not increase vascular permeability, cause vasoconstriction, or prevent further hemorrhage.
The nurse is planning care for a client experiencing agnosia secondary to a cerebrovascular accident. Which collaborative intervention will be included in the plan of care? 1. Observe the client swallowing for possible aspiration. 2. Position the client in a semi-Fowler's position when sleeping. 3. Place a suction setup at the client's bedside during meals. 4. Refer the client to an occupational therapist for evaluation.
4 1. Agnosia is the failure to recognize familiar objects; therefore, observing the client for possible aspiration is not appropriate. 2. A semi-Fowler's position is appropriate for sleeping, but agnosia is the failure to recognize familiar objects; therefore, this intervention is inappropriate. 3. Placing suction at the bedside will help if the client has dysphagia (difficulty swallowing), not agnosia, which is failure to recognize familiar objects. 4. A collaborative intervention is an intervention in which another health-care discipline—in this case, occupational therapy—is used in the care of the client. TEST TAKING HINT: Be sure to look at what the question is asking and see if the answer can be determined even if some terms are not understood. In this case, note that the question refers to "collaborative intervention." Only option "4" refers to collaboration with another discipline
The 85-year-old client diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first? 1. Administer a nonnarcotic analgesic. 2. Prepare for STAT magnetic resonance imaging (MRI). 3. Start an intravenous infusion with D5W at 100 mL/hr. 4. Complete a neurological assessment.
4 1. The nurse should not administer any medication to a client without first assessing the cause of the client's complaint or problem. 2. An MRI scan may be needed, but the nurse must determine the client's neurological status prior to diagnostic tests. 3. Starting an IV infusion is appropriate, but it is not the action the nurse should implement when assessing pain, and 100 mL/hr might be too high a rate for an 85-year-old client. 4. The nurse must complete a neurological assessment to help determine the cause of the headache before taking any further action. TEST TAKING HINT: The test taker should always apply the nursing process when answering questions. If the test taker narrows down the choices to two possible answer options, always select the assessment option as the first intervention.
The client has been diagnosed with a cerebrovascular accident (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? 1. Obtain a rubber mat to place under the dinner plate. 2. Purchase a long-handled bath sponge for showering. 3. Purchase clothes with Velcro closure devices. 4. Obtain a raised toilet seat for the client's bathroom.
4 1. The rubber mat will stabilize the plate and prevent it from slipping away from the client learning to feed himself, but this does not address generalized weakness. 2. A long-handled bath sponge will assist the client when showering hard-to-reach areas, but it is not a home modification nor will it help with generalized weakness. 3. Clothes with Velcro closures will make dressing easier, but they do not constitute a home modification and do not address generalized weakness. 4. 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. TEST TAKING HINT: The test taker must read the stem of the question carefully and note that the intervention must be one in which the home is modified in some way. This would eliminate thre
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? 1.Wear a patch over one eye. 2.Place personal items on the sighted side. 3.Lie in bed with the unaffected side toward the door. 4.Turn the head from side to side when walking."
4 To expand the visual field, the partially sighted client should be taught to turn the head from side to side when walking. Neglecting to do so may result in accidents. This technique helps maximize the use of remaining sight. Covering an eye with a patch will limit the field of vision. Personal items can be placed within sight and reach, but most accidents occur from tripping over items that cannot be seen. It may help the client to see the door, but walking presents the primary safety hazard
A client with a hemorrhagic stroke is slightly agitated, heart rate is 118, respirations are 22, bilateral rhonchi are auscultated, SpO2 is 94%, blood pressure is 144/88, and oral secretions are noted. What order of interventions should the nurse follow when suctioning the client to prevent increased intracranial pressure (ICP) and maintain adequate cerebral perfusion? 1. Suction the airway. 2. Hyperoxygenate. 3. Suction the mouth. 4. Provide sedation.
4 Provide sedation. 2. Hyperoxygenate. 1. Suction the airway. 3. Suction the mouth. Increased agitation with suctioning will increase ICP; therefore, sedation should be provided first. The client should be hyperoxygenated before and after suctioning to prevent hypoxia since hypoxia causes vasodilation of the cerebral vessels and increases ICP. The airway should then be suctioned for no more than 10 seconds. The mouth can be suctioned once the airway is clear to remove oral secretions. Once the mouth is suctioned, the suction catheter should be discarded.
During the acute phase of a stroke, the nurse assesses the patient's vital signs and neurologic status every 4 hours. What is a cardiovascular sign that the nurse would see as a body attempts to increase cerebral blood flow? a. Hypertension b. Fluid overload c. Cardiac dysrhythmias d. S3 and S4 heart sounds
A The body responds to the vasospasm and decreased circulation to the brain that occurs with a stroke by increasing the BP, frequently resulting in hypertension. The other options are important cardiovascular factors to assess but they do not result from impaired cerebral blood flow.
A newly admitted patient diagnosed with right-sided brain stroke has a nursing diagnosis of disturbed visual sensory perception related to homonymous hemianopsia. Early in the care of the patient, what should the nurse do? a. Place objects on the right side within the patient's field of vision. b. Approach the patient from the left side to encourage the patient to turn the head. c. Place objects on the patient's left side to assess the patient's ability to compensate. d. Patch the affected eye to encourage the patient to turn the head to scan the environment.
A The presence of homonymous hemianopia in a patient with right hemisphere brain damage causes a loss of vision in the left field bilaterally. Early in the care of the patient, objects should be placed on the right side of the patient in the field of vision and the nurse should approach the patient from the right side. Later in treatment, patients should be taught to turn the head and scan the environment and should be approached from the affected side to encourage head turning. Eye patches are used if patients have diplopia (double vision).
What is an appropriate food for a patient with a stroke who has mild dysphagia? a. Fruit juices b. Pureed meat c. Scrambled eggs d. Fortified milkshakes
C Soft foods that promote enough texture, flavor, and bulk to stimulate swallowing should be used for the patient with dysphagia. Thin liquids are difficult to swallow and patients may not be able to control them in the mouth. Pureed foods are often too bland and too smooth and milk products should be avoided because they tend to increase the viscosity of mucus and increase salivation.
What is a nursing intervention that is indicated for the patient with hemiplegia? a. The use of a footboard to prevent plantar flexion b. Immobilization of the affected arm against the chest with a sling c. Positioning the patient in bed with each joint lower than the joint proximal to it d. Having the patient perform passive range of motion (ROM) of the affected limb with the unaffected limb
D Active range of motion (ROM) should be initiated on the unaffected side as soon as possible and passive ROM of the affected side should be started on the first day. Having the patient actively exercise the unaffected side provides the patient with active and passive ROM as needed. Use of footboards is controversial because they stimulate plantar flexion. The unaffected arm should be supported but immobilization may precipitate a painful shoulder-hand syndrome. The patient should be positioned with each joint higher than the joint proximal to it to prevent dependent edema.
What is the priority intervention in the emergency department for the patient with a stroke? a. Intravenous fluid replacement b. Administration of osmotic diuretics to reduce cerebral edema c. Initiation of hypothermia to decrease the oxygen needs of the brain d. Maintenance of respiratory function with patent airway and oxygen administration
D The first priority in acute management of the patient with a stroke is the preservation of life. Because the patient of a stroke may be unconscious or have a reduced gag reflex, it is most important to maintain a patent airway for the patient and provide oxygen if respiratory effort is impaired. IV fluid replacement, treatment with osmotic diuretics, and avoiding hyperthermia may be used for further treatment
