2300 U14 Intracranial Regulation, CVA, Seizures

Transient ischemic attacks are: A) Temporary episodes of neurologic dysfunction B) Periods of alternating exacerbations and remissions of neurologic disease C) Attacks caused by multiple small emboli D) Ischemic attacks which result in progressive neurologic deterioration

A

Which clinical manifestation does the nurse expect in the client in the postictal phase of generalized tonic-clonic seizure? A) Drowsiness B) Inability to move C) Paresthesia D) Hypotension

A

A client arrives in the emerency department with an ischemic stroke and receives recombinant tissue plasminogen activator alteplase (t-Pa) administration. Which is the priority nursing assessment/why is he given this drug? A) Current medications B) Complete physical and history C) Time of onset of current stroke D) Upcoming surgical procedure

C

In which position in bed should the nurse place the client after the seizure has ended? A) Low mid Fowler's position B) Side lying position C) Supine position D) Modified Trendelenburg position

B

Mrs. Edna Cowan has had a CVA affecting the right side of her body. Before initiating oral feeding for the first time for Mrs. Cowan, which nursing action is most important? A) Position Mrs. Cowan in an upright position. B) Assess Mrs. Cowan for the presence of the gag reflex. C) Assess Mrs. Cowan's ability to swallow ice chips or water before offering food D) Suction Mrs. Cowan's oral cavity to prevent aspiration of secretions

B

The client's family asked the nurse what the definition of a cerebrovascular accident is. How should the nurse describe this? A) It is a sudden change in the blood pressure, resulting in damage to the brain. B) It is a disruption in the normal blood supply to the brain, producing focal neurologic deficits. C) It is fluctuations in blood flow, leading to dizziness and subsequent falls. D) It is increased blood flow, resulting in hemorrhage and subsequent tissue damage.

B

The nurse assesses the client who has suffered a CVA. The client is able to speak but the phrases have little meaning. The nurse determines that the client has A) Expressive aphasia (Broca's) B) Receptive aphasia (Wernicke's) C) Dysarthria D) Amnesic aphasia

B

The nurse is teaching the family of a client with dysphagia from a CVA about decreasing the risk of aspiration while eating. Which of the following strategies is inappropriate? A) Maintaining an upright position 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

B

What is a priority nursing assessment in the first 24 hours after admission of the client with thrombotic stroke? A) Cholesterol level B) Pupil size and pupillary response C) Bowel sounds D) Echocardiogram

B

When communicating with a client who has aphasia, which of the following nursing interventions is inappropriate? A) Present one thought at a time B) Encourage the client NOT to write messages C) Speak with normal volume D) Make use of gestures

B

When preparing to teach a client about phenytoin sodium (Dilantin) therapy, the nurse should urge the client not to stop the drug suddenly because: A) Physical dependency on the drug develops over time B) Status epilepticus may develop C) a hypoglycemic reaction develops D) a heart block is likely to develop

B

A client is experiencing mood swings after a stroke ( brain cell injury related) 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 attention D) Tell the client that this behavior is unacceptable

C

An 87 year old client is admitted with a stroke. During the admission interview and assessment, his speech is slow, non-fluent, and labored. How should the nurse document this finding? A) Receptive aphasia B) Wernicke's aphasia C) Expressive aphasia D) Global aphasia

C

During the first 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal is to control the client's A) Pulse B) Respirations C) Blood pressure D) Temperature

C

The female client presents to the emergency department diagnosed with a stroke. Which of the client's current medication regimen is a risk factor for developing a stroke? A) Propranolol (lnderal) a beta blocker B) Furosemide (Lasix) a loop diuretic C) Estradiol/norgestimate (Ortho-Cyclen), a combination hormone of estrogen& progestational compounds D) Metformin (Glucophage), a biguanide

C

What is the expected outcome of thrombolytic drug therapy (fibrinolytic therapy) for stroke? A) Increased vascular permeability B) Vasoconstriction C) Dissolved emboli D) Prevention of hemorrhage

C

What is the priority nursing intervention in the postictal phase of a seizure? A) Reorient the client to time, person and place B) Determine the client's level of sleepiness C) Assess the client's breathing pattern D) Position the client comfortably

C

When a client is admitted to the hospital in an unconscious state following subarachnoid hemorrhage resulting from a ruptured intracranial aneurysm, the nurse anticipates that the manifestations that preceded the loss of consciousness were A) generalized weakness and fatigue accompanied by anorexia B) gradual loss of speech or vision C) sudden severe headache accompanied by vomiting D) weakness, fever, nausea, and vomiting

C

Which of the following is the priority safety intervention when protecting the patient having a seizure? A) Placing a tongue blade between their teeth B) Ensure that the patient is restrained C) Position the patient to prevent aspiration of secretions D) Determine if the patient is incontinent

C

A nurse is planning to institute seizure precautions for a client who is being admitted from the emergency department. Which of the following measures would the nurse avoid in planning for the client's safety?(check all that apply) A) Placing an airway, oxygen, and suction equipment at the bedside. B) Padding the side rails of the bed C) Putting a padded tongue blade at the head of the bed D) Having IV eqiuipment ready for insertion of an IV access E) Restraining the client's limbs

C, E

Which of the following will the nurse observe in the client in the ictal phase of a generalized tonic-clonic seizure (grand mal) A) Jerking in one extremity that spreads gradually to adjacent areas B) Vacant staring and abruptly ceasing all activity C) Facial grimaces, patting motions, and lip smacking D) Loss of consciousness, body stiffening, and violent muscle contractions

D