Ch. 38 Review Q's (NCLEX Style)

An elderly client, who has fallen several times at home, is admitted for possible transient ischemic attack (TIA). Which assessment finding is most significant in determining care for this client? A) Becomes confused during the night B) Drooling from side of mouth C) Bruit heard over carotids D) Irregular heart rhythm

B) Drooling from side of mouth

Following the use of a thrombolytic agent in the management of cerebrovascular accident (CVA) client, which is the priority nursing assessment? A) Pulse B) Respirations C) Airway D) Blood pressure

D) Blood pressure

A client with atrial fibrillation is placed on Coumadin to reduce the potential of developing a cerebrovascular accident (CVA). The international normalized ratio (INR) is 1.5. What does this finding indicate to the nurse? A) Therapeutic range is achieved. B) Coumadin will be increased. C) Coumadin will be decreased. D) INR is too high.

B) Coumadin will be increased.

The client with hemiplegia is at risk for impaired walking. Which nursing intervention would best assist this client in preventing complications associated with lower extremity impairment? A) Occupational therapy daily B) Use of walker for ambulation C) Use of high-top tennis shoes throughout the day D) Whirlpool tub baths and massage therapy

C) Use of high-top tennis shoes throughout the day

A client presents to the walk-in clinic complaining of a migraine. The client is prescribed a neuronal stabilizer. What should the nurse suggest to the client? A) Avoid crowds. B) Take drugs only after meals at night. C) Avoid caffeine and alcohol. D) Use caution while driving or performing hazardous activities.

D) Use caution while driving or performing hazardous activities.

A client who has experienced an initial transient ischemic attack (TIA) states: ìI'm glad it wasn't anything serious.î Which is the best nursing response to this statement? A) ìI sense that you are happy it was not a stroke.î B) ìPeople who experience a TIA will develop a stroke.î C) ìTIA symptoms are short lived and resolve within 24 hours.î D) ìTIA is a warning sign. Let's talk about lowering your risks.î

D) ìTIA is a warning sign. Let's talk about lowering your risks.î

A client with a history of atrial fibrillation has experienced a TIA. In an effort to reduce the risk of cerebrovascular accident (CVA), the nurse anticipates the medical treatment to include which of the following? A) Cholesterol-lowering drugs B) Anticoagulant therapy C) Monthly prothrombin levels D) Carotid endarterectomy

B) Anticoagulant therapy

A client is prescribed warfarin. Client teaching has included instructions to avoid a diet rich in foods that contain vitamin K. What sources of food should the nurse instruct the client to avoid? A) Fish, meats, and vegetable oils B) Citrus fruits C) Milk and dairy products D) Cereals, soybeans, and spinach

D) Cereals, soybeans, and spinach

When providing teaching to a client who reports tension headaches, which of the following instructions would be most beneficial to prevent onset of symptoms? A) Apply cool or warm cloth to head or eyes. B) Eliminate use of bright lights when working. C) Avoid certain foods. D) Perform stretching exercises and frequent position change.

D) Perform stretching exercises and frequent position change.

A client is admitted to the intensive care unit (ICU) with a diagnosis of cerebrovascular accident (CVA). Which assessment by the nurse provides the most significant finding in differentiating between ischemic and hemorrhagic strokes? A) A unit of fresh frozen plasma is infusing. B) Neurological checks are ordered every 2 hours. C) Keppra is ordered for treatment of focal seizures. D) Oropharyngeal suctioning as needed.

A) A unit of fresh frozen plasma is infusing.

A client has just been diagnosed with a cerebral aneurysm. In planning discharge teaching for this client, what instructions should be delivered by the nurse to the client? A) Avoid heavy lifting. B) Avoid fiber in the diet. C) Take an antacid frequently. D) Take an herbal form of feverfew.

A) Avoid heavy lifting.

A 76-year-old male client is brought to the clinic by his daughter. The daughter states that her father has had two transient ischemic attacks (TIAs) in the past week. The physician orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option does the nurse expect the physician to offer this client to increase blood flow to the brain? Select all that apply. A) Balloon angioplasty of the carotid artery followed by stent placement B) Removal of the carotid artery C) Percutaneous transluminal coronary artery angioplasty D) Carotid endarterectomy

A) Balloon angioplasty of the carotid artery followed by stent placement D) Carotid endarterectomy

A client diagnosed with migraine headaches asks the nurse what he can do to help control the headaches and minimize the number of attacks he is having. What instructions should the nurse give this client? A) Identify and avoid factors that precipitate or intensify an attack. B) Keep a record of activities following an attack. C) When an attack occurs, stay in a brightly lit area. D) Write down any adverse drug effects.

A) Identify and avoid factors that precipitate or intensify an attack.

You are caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke do you know this client has? A) Ischemic B) Hemorrhagic C) Right-sided D) Left-sided

A) Ischemic

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) Transient ischemic attack (TIA) B) Left-sided cerebrovascular accident (CVA) C) Right-sided cerebrovascular accident (CVA) D) Completed Stroke

B) Left-sided cerebrovascular accident (CVA)

A client is brought to the emergency department with symptoms of a cerebrovascular accident (CVA). The nurse would anticipate which diagnostic evaluation to be completed prior to initiation of treatment? A) Prothrombin level B) Chest x-ray C) Brain CT scan or MRI D) Lumbar puncture

C) Brain CT scan or MRI

While making your initial rounds after coming on shift, you find a client thrashing about in bed complaining of a severe headache. The client tells you the pain is behind his right eye, which is red and tearing. What type of headache would you suspect this client of having? A) Migraine B) Tension C) Cluster D) Sinus

C) Cluster

A client is brought into the emergency department with a diagnosis of ruptured cerebral aneurysm. Which assessment data provides the most important information in preparing for the nursing care of this client? A) Blood pressure 180/98 mm Hg B) Alert and oriented times three C) Grade V on the Hunt-Hess Scale D) Complaint of severe splitting headache

C) Grade V on the Hunt-Hess Scale

Which nursing assessment finding is most indicative of a hemorrhagic stroke? A) Client history of atrial fibrillation B) Sudden onset of breathing alterations C) Symptoms evolving over 24 to 48 hours D) Client history of hyperlipidemia

B) Sudden onset of breathing alterations

The nurse is assisting a client, with a right-sided brain infarction, to transfer from the wheelchair to the bed. Which is the best placement of the wheelchair to facilitate this transfer? A) Wheelchair placed so client leads with his left side B) Wheelchair placed on the right side of the bed facing the foot C) Wheelchair placed on the left side of the bed facing the head D) Wheelchair placed on the right side of the bed facing the head

B) Wheelchair placed on the right side of the bed facing the foot

A client has tension headaches. The nurse recommends massage as a treatment for tension headaches. How does massage help clients with tension headaches? A) Reduces hypotension B) Increases appetite C) Relaxes muscles D) Relieves migraines

C) Relaxes muscles

The nurse is caring for a client with a cerebral aneurysm. Why does the nurse limit the interaction of visitors or family members with the client with an aneurysm? A) The interaction may cause the client to become violent. B) The interaction may cause migraine in the client. C) The stimulation can increase intracranial pressure (ICP) or trigger a seizure. D) The client may become emotional and lose interest in the treatment.

C) The stimulation can increase intracranial pressure (ICP) or trigger a seizure.

The client with a cerebral aneurysm asks the nurse, ìWhat's the big fuss over a headache?î Which is the best response from the nurse regarding to a cerebral aneurysm? A) ìDon't worry. The aneurysm has probably been there since birth.î B) ìThe headache can be an indication that the aneurysm is growing.î C) ìA headache means your aneurysm is leaking blood into the brain.î D) ìYour physician wants to evaluate the location and condition of the aneurysm.î

D) ìYour physician wants to evaluate the location and condition of the aneurysm.î

A client has experienced a transient ischemic attack (TIA) and presents with carotid bruits. Which is the priority action to be taken by the nurse, following a bilateral carotid endarterectomy? A) Encourage deep breathing and coughing. B) Observe for facial swelling. C) Anticipate need for endotracheal intubation. D) Resume antilipemic drugs.

C) Anticipate need for endotracheal intubation.

A family member comes to the clinic to talk to the nurse about a client who has had a stroke on the right side of the brain. The family member is concerned because of the deficits the client is exhibiting. The nurse knows that when a client experiences a stroke on the right side of the brain, common deficits include what? Select all that apply. A) Left-sided hemiplegia B) Tendency to distractibility C) Impairment of long-term memory D) Hyperaware of deficits E) Neglect of objects and people on the left side

A) Left-sided hemiplegia B) Tendency to distractibility E) Neglect of objects and people on the left side

A client with a cerebrovascular accident (CVA) is having difficulty with eating food on the plate. Which is the best nursing action to be taken? A) Perform a vision field assessment. B) Reposition the tray and plate. C) Assist the client with feeding. D) Know this is a normal finding for CVA.

A) Perform a vision field assessment.

The nurse is completing an assessment on a client with a history of migraines. The nurse would identify which of the following factors as a possible trigger for a migraine headache? Select all that apply. A) Red wine B) Nausea C) Menstruation D) Exposure to bright light E) Change in environmental temperature F) Prolonged positioning

A) Red wine C) Menstruation

Which of the following goals is the priority in the care planning of a client with cerebrovascular accident (CVA) who is being transferred to a rehabilitation unit? A) To prevent contractures and joint deformities B) To decrease risk for ineffective cerebral tissue perfusion C) To develop appropriate coping mechanisms D) To increase activity tolerance

A) To prevent contractures and joint deformities

A client is being assessed for a possible transient ischemic attack (TIA). Which of the following assessment findings suggests to the nurse that the client is experiencing a TIA? A) Unilateral ptosis B) Respiratory distress C) Severe headache D) Nausea and vomiting

A) Unilateral ptosis

A client is prescribed sumatriptan (Imitrex) for the treatment of migraine headache. Which client statement would indicate a need for additional teaching from the nurse? A) ìI use this to prevent migraines.î B) ìI take this when I get a headache.î C) ìIt constricts the blood vessels in my head.î D) ìIt alleviates my sensitivity to light and sound.î

A) ìI use this to prevent migraines.î

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? A) Cluster headaches can cause severe debilitating pain. B) Migraines often coincide with menstrual cycle. C) Tension headaches are easier to treat. D) Headaches are the most common type of reported pain.

B) Migraines often coincide with menstrual cycle.

A client has been found unresponsive at home for an undetermined period of time. A cerebrovascular accident (CVA) is suspected, and the family is demanding a clot buster be used to restore functioning. The nurse knows that successful use of TPA in a client with CVA requires which of the following? Select all that apply. A) The symptoms are no longer evolving. B) Presence of an ischemic stroke C) Used concurrently with heparin therapy D) Administer intramuscular for faster response. E) Administer within 3 hours of onset of symptoms. F) Administer for hemorrhagic strokes.

B) Presence of an ischemic stroke E) Administer within 3 hours of onset of symptoms.

A video fluoroscopy 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? A) Risk for Fluid Volume Deficit B) Risk for Aspiration C) Impaired Swallowing D) Altered Nutrition: Less Than Body Requirements

C) Impaired Swallowing

A client is admitted for evaluation of cerebral aneurysm. Which assessment finding is of greatest importance in prioritizing nursing care to this client? A) Complaint of headache off and on for past month B) No bowel movement since yesterday C) Nausea D) Frequent voiding

C) Nausea