Chapter 28: Cerebrovascular Accident

33. A nurse checks the oxygen in the circulating volume for adequate concentration to support the brain's need of _____% of the oxygen supply of the body.

ANS: 20 The brain requires 20% of the available oxygen to function and to avoid hypoxic damage. DIF: Cognitive Level: Knowledge REF: p. 482 OBJ: 7 TOP: Oxygen Needs of the Brain KEY: Nursing Process Step: Implementation

24. Which posthospital option should the nurse encourage a patient to do when recovering from a CVA to provide the most comprehensive assistance? a. Transfer to a rehabilitation center. b. Discharge to home with scheduled visits from home health care nurses. c. Discharge to home with scheduled visits from a physical therapist. d. Discharge to home with scheduled visits from an occupational therapist.

ANS: A A rehabilitation center with all modalities of support (e.g., physical therapy, occupational therapy, speech therapy, simulated home environments) is obviously the best option. DIF: Cognitive Level: Comprehension REF: p. 506 OBJ: 10 TOP: Postdischarge Planning KEY: Nursing Process Step: Planning

9. A patient in the acute phase of a CVA who has been speaking distinctly begins to speak indistinctly and only with great effort but still coherent. What should this nurse determine when assessing this patient? a. Stroke in evolution with dysarthria b. Lacunar stroke with fluent aphasia c. Complete stroke with global aphasia d. Stroke in evolution with dyspraxia

ANS: A As symptoms worsen, the CVA is still evolving. Speech that is coherent but difficult is dysarthria rather than any type of aphasia. Dyspraxia is a motor impairment, not a speech impairment. DIF: Cognitive Level: Analysis REF: p. 490 OBJ: 4 TOP: CVA Deficits KEY: Nursing Process Step: Assessment

4. A nurse is updating a teaching plan for a patient who sustained a TIA. What should the nurse be sure to include? a. Daily aspirin dose b. Long rest periods daily c. Reduction of fluid intake to 800 mL/day d. High-carbohydrate diet

ANS: A Daily aspirin reduces platelet aggregation and may prevent another attack. Reductions of fluid and long rest periods encourage clot formation. DIF: Cognitive Level: Application REF: p. 485 OBJ: 3 TOP: Post-TIA Teaching KEY: Nursing Process Step: Planning

23. Which instruction is most helpful in teaching the family and patient who is in the rehabilitation phase after a CVA about altered sensation? a. Make frequent assessments for signs of pressure or injury. b. Use the affected side in supporting the patient in ambulation and transfer to stimulate better sensation. c. Apply ice packs to the affected limbs to encourage a return of sensation. d. Apply a heating pad to the affected limbs to increase circulation.

ANS: A Frequent assessment using the National Institutes of Health Stroke Scale will allow early detection. The use of hot or cold applications and using the affected limbs in transfer or ambulation may cause injury. DIF: Cognitive Level: Application REF: p. 503 OBJ: 8 TOP: Altered Sensation KEY: Nursing Process Step: Planning

1. A patient has weakness on the right side and impaired reasoning after having a cerebrovascular accident (CVA). What part of the brain is affected? a. Left hemisphere of the cerebrum b. Right hemisphere of the cerebrum c. Left cerebellum d. Right cerebellum

ANS: A Impaired motor strength on the right side in conjunction with impaired reasoning indicates a lesion in the left hemisphere of the cerebrum. The cerebellum controls balance and is not contralateral. DIF: Cognitive Level: Comprehension REF: p. 481-482 OBJ: 3 TOP: Symptoms of a CVA KEY: Nursing Process Step: Assessment

12. A patient who has sustained a hemorrhagic stroke is placed on a protocol of 60 mg of calcium channel blocker (nimodipine) every 4 hours. The patient's pulse is 82 beats/min before the administration of the prescribed dose. Which action should the nurse implement? a. Give the full dose as prescribed without further assessment. b. Omit the dose, recording the pulse rate as the rationale. c. Delay the dose until the pulse is below 60 beats/min. d. Give half of the prescribed dose (30 mg).

ANS: A The dose should be given; it would be held only if the pulse is below 60 beats/min. Assessments should be made regarding BP, urine output, and edema. DIF: Cognitive Level: Application REF: p. 487 OBJ: 3 TOP: CVA Medical Protocol KEY: Nursing Process Step: Implementation

10. Several days after a CVA, a patient's family asks a nurse if tissue plasminogen activator (tPA) is a drug therapy option now. The nurse's response is based on the knowledge that this drug must be used within how many hours after the onset of symptoms? a. 3 b. 5 c. 10 d. 24

ANS: A tPA is to be given within 3 hours of the onset of symptoms per the U.S. Food and Drug Administration's guidelines. In some special treatment centers this drug is given intravenously up to 6 hours after the stroke. DIF: Cognitive Level: Knowledge REF: p. 492 OBJ: 6 TOP: CVA Medication Implementation KEY: Nursing Process Step: Implementation

31. Which home modifications will support rehabilitation for a patient who had a stroke? (Select all that apply.) a. Raised commode seat b. Provision of a seat in the shower c. Availability of soft, low chairs d. Bathtub hand rails e. Bright-colored scatter rugs

ANS: A, B, D A raised commode seat, a seat in the shower, and bathtub rails assist the patient who is recovering from a stroke with self-care. Low chairs are difficult to manage, and scatter rugs pose a hazard for falls. DIF: Cognitive Level: Comprehension REF: p. 503 OBJ: 8 TOP: Home Modification KEY: Nursing Process Step: Planning

32. What causes the 3% of strokes known to occur in persons younger than 45 years of age? (Select all that apply.) a. Drug abuse b. Alcohol abuse c. Birth control pills d. Sickle cell anemia e. Hemophilia

ANS: A, C, D Strokes in younger people are caused by drug abuse, birth control pills, sickle cell anemia, leukemia, atrial fibrillation, and rheumatic fever. Alcohol abuse and hemophilia do not have a causative role in stroke. DIF: Cognitive Level: Knowledge REF: p. 483 OBJ: 3 TOP: Stroke in Young Persons KEY: Nursing Process Step: Planning

30. Which patients with CVAs are considered candidates for treatment with tPA? (Select all that apply.) a. A 62-year-old construction worker who had a subdural hematoma 6 months earlier b. A 58-year-old executive with a bleeding ulcer c. A 44-year-old individual who had a seizure at the onset of a stroke d. A 40-year-old individual who is taking warfarin (Coumadin) and has an INR of 2.5 e. A 19-year-old young adult with leukemia with a platelet count of 200,000

ANS: A, E The criteria for exclusion are a head injury within the last 3 months, a platelet count less than 100,000, active gastrointestinal bleeding, current treatment with an anticoagulant, and a seizure noted at the time of the CVA. DIF: Cognitive Level: Application REF: p. 492 OBJ: 6 TOP: Drugs to Treat CVA KEY: Nursing Process Step: Assessment

7. What should a nurse ensure as a priority for a patient immediately after a CVA? a. Preservation of motor function b. Airway maintenance c. Adequate hydration d. Control of elimination

ANS: B Adequate oxygenation prevents hypoxemia, which can extend and worsen effects of the CVA. DIF: Cognitive Level: Application REF: p. 491 OBJ: 7 TOP: Nursing Care of Acute CVA KEY: Nursing Process Step: Planning

11. A nurse explains that a lumbar puncture is most helpful as a diagnostic tool for a new patient who has had a CVA. What would this diagnostic test help determine regarding the stroke? a. It is lacunar. b. It is hemorrhagic or embolic. c. It is complete or in evolution. d. It will result in paralysis.

ANS: B Blood in the spinal fluid indicates a hemorrhagic stroke and will help direct medical protocol in the subsequent treatment. DIF: Cognitive Level: Comprehension REF: p. 491 OBJ: 5 TOP: CVA Diagnostic Tests KEY: Nursing Process Step: N/A

5. A patient recovering from a CVA asks the purpose of the warfarin (Coumadin). What is the best response by the nurse regarding the purpose of Coumadin? a. Dissolves the clot. b. Prevents the formation of new clots. c. Dilates the vessels to improve blood flow. d. Suppresses the formation of platelets.

ANS: B Coumadin and heparin prevent more clots rather than dissolving them. Coumadin has no effect on vasodilation or blood cell production. DIF: Cognitive Level: Comprehension REF: p. 486 OBJ: 3 TOP: Coumadin Therapy KEY: Nursing Process Step: Implementation

19. A patient with homonymous hemianopsia is in the rehabilitation phase of a CVA. When arranging this patient's environment where should the nurse assure persons approaching and important items are visible and available? a. Unaffected side b. Affected side c. Direct front d. Either side

ANS: B Making the patient scan the affected side helps stimulate the return of normal function in the rehabilitation phase. DIF: Cognitive Level: Application REF: p. 504 OBJ: 8 TOP: Hemianopsia KEY: Nursing Process Step: Planning

13. During the acute CVA phase, a risk for falls related to paralysis is present. Which intervention best protects the patient from injury? a. Keep the bed in a high position for ease of nursing care. b. Keep the side rails up, according to agency policy. c. Assess vision deficit related to ptosis. d. Monitor the condition every 2 hours.

ANS: B Rails keep patients in bed. The bed should be low, monitoring the patient should be more frequent than every 2 hours, and visual assessment is not directly related to fall prevention. DIF: Cognitive Level: Application REF: p. 495 OBJ: 8 TOP: Acute Care: Fall Prevention KEY: Nursing Process Step: Implementation

17. A patient in the acute phase of an embolic CVA has an order for 400 units of heparin per hour IV. The heparin is in a solution of 5000 units/100 mL normal saline (NS). The nurse should set the electronic IV monitor at how many milliliters per hour? a. 6 b. 8 c. 10 d. 16

ANS: B Regardless of the method of calculation, 50 units of heparin are in each milliliter of the solution; 8 mL/hr delivers 400 units (5000 units ÷ 100 mL NS = 50 units/mL. 400 units ÷ 50 units/mL = 8 mL). DIF: Cognitive Level: Analysis REF: p. 485-486 OBJ: 8 TOP: Heparin Therapy KEY: Nursing Process Step: Implementation

26. Which transitory symptoms might occur when a patient is diagnosed with a TIA? (Select all that apply.) a. Incontinence b. Dysphagia c. Ptosis d. Tinnitus e. Dysarthria

ANS: B, C, D, E All, except transitory incontinence, are classic symptoms of a TIA. These deficits usually disappear without permanent disability in approximately 24 hours. DIF: Cognitive Level: Comprehension REF: p. 484-485 OBJ: 3 TOP: Symptoms of TIA KEY: Nursing Process Step: Assessment

6. A patient has had a complete stroke as a result of a ruptured vessel in the left hemisphere. How should this patient's CVA be classified? a. Ischemic, embolic b. Hemorrhagic, subarachnoid c. Hemorrhagic, intracerebral d. Ischemic, thrombotic

ANS: C A ruptured vessel in a hemisphere is an intracerebral hemorrhagic CVA. It did not occur in the subarachnoid space. Ischemic CVAs are the result of occluded vessels. DIF: Cognitive Level: Analysis REF: p. 487 OBJ: 2 TOP: CVA Classification KEY: Nursing Process Step: Assessment

15. Which assessment indicates a fluid volume excess in a patient in the acute phase of a CVA? a. Decreased BP b. Weak pulse c. Adventitious breath sounds d. High urine-specific gravity

ANS: C Crackles in the lung fields are a major indicator of fluid excess. The pulse and BP are elevated in fluid excess. Urine-specific gravity is low in fluid excess. DIF: Cognitive Level: Application REF: p. 499 OBJ: 8 TOP: Fluid Excess KEY: Nursing Process Step: Assessment

21. Which is the most effective intervention for best support of regular bowel elimination and the prevention of constipation? a. Limit fluid intake from 32 to 50 oz daily to compact the stool. b. Administer small soapsuds enema every other day to cleanse the bowel. c. Give stool softeners daily, establishing a consistent time to attempt elimination. d. Administer a strong laxative on a daily basis to encourage evacuation.

ANS: C Daily stool softeners, rather than daily laxatives or frequent enemas, help restore regularity and bowel tone. DIF: Cognitive Level: Application REF: p. 506 OBJ: 8 TOP: Bowel Elimination KEY: Nursing Process Step: Planning

16. Which intervention should the nurse include in a patient's plan of care to help preserve joint mobility in the acute phase of a CVA? a. Pull the limbs on the affected side into a functional position. b. Perform aggressive full range-of-motion exercises for all extremities. c. Support affected points in good functional alignment. d. Exercise the limbs every 8 hours.

ANS: C Limbs maintained in a functional anatomic position and gently exercised (never pulled) into an acceptable range of motion several times during a shift will maintain optimal mobility. DIF: Cognitive Level: Application REF: p. 500-501 OBJ: 8 TOP: Preserving Joint Mobility KEY: Nursing Process Step: Implementation

20. Which outcome criterion is the most appropriate for a patient with "Imbalanced nutrition, related to dysphagia, with the goal of adequate nutrition"? a. Offers a variety of food groups b. Eats half of all meals offered c. Maintains body weight of 150 to 155 lb d. Eats all meals independently

ANS: C The maintenance of a desired weight is indicative of adequate nutrition. Eating a portion of a meal or eating independently does not adequately measure the extent to which the goal was met. Offering a variety of foods is a nursing or dietary function, not an outcome. DIF: Cognitive Level: Application REF: p. 504 OBJ: 9 TOP: Rehabilitation: Nutrition KEY: Nursing Process Step: Planning

27. What purposes exist for a stent in the carotid artery of a person with a TIA? (Select all that apply.) a. Capture circulating clots. b. Help with subsequent angioplasties. c. Keep the artery open. d. Prevent hemorrhage. e. Measure the pressure in the artery.

ANS: C The only purpose of a stent is to keep an artery open. DIF: Cognitive Level: Knowledge REF: p. 485 OBJ: 3 TOP: Use of Stent KEY: Nursing Process Step: Implementation

18. Which assessment indicates that a patient with a CVA is in transition to the rehabilitation phase? a. BP has been within normal limits for 24 hours. b. Patient makes positive statements about his condition. c. No further neurologic deficits are observed. d. Successful attempts are made at independent function.

ANS: C When no further deficits are noted and all vital signs have stabilized, the patient is considered to be in the rehabilitation phase. Positive statements and attempts at independence are not sufficient. DIF: Cognitive Level: Application REF: p. 502 OBJ: 8 TOP: Rehabilitation Phase KEY: Nursing Process Step: Assessment

29. How does a lacunar stroke differ from an ischemic CVA? (Select all that apply.) a. Causes a great deal of pain b. Alters the personality c. Affects small arteries d. Nearly always results in blindness e. Produces a small amount of neurologic damage

ANS: C, E The lacunar CVA only affects small arteries and produces a small amount of neurologic damage. DIF: Cognitive Level: Comprehension REF: p. 488 OBJ: 2 TOP: Lacunar CVA KEY: Nursing Process Step: Implementation

3. A patient experienced a period of momentary confusion, dizziness, and slurred speech but recovered in 2 hours. Which assessment in the diagnosis of this episode would be most helpful? a. Patient's complaint of nausea b. Blood pressure (BP) of 140/90 mm Hg c. Patient's complaint of headache d. Auscultation of a bruit over the carotid artery

ANS: D A carotid bruit is evidence of a narrowing in that vessel, a symptom of a possible CVA or transient ischemic attack (TIA). BP of 140/90 mm Hg, although at the high end, is considered within normal limits. Headache and nausea alone are too common to be definitive. DIF: Cognitive Level: Application REF: p. 485 OBJ: 2 TOP: TIA Diagnosis KEY: Nursing Process Step: Assessment

14. Pneumonia is the most frequent cause of death after a stroke. Which intervention would be contraindicated in the acute care of a patient with a hemorrhagic CVA? a. Thicken liquids to ease swallowing and prevent aspiration. b. Change position every 30 to 60 minutes. c. Maintain adequate fluid intake, orally or IV. d. Encourage forceful coughing to stimulate deep breathing.

ANS: D Forceful coughing is contraindicated for the patient with a hemorrhagic CVA because it may cause increased intracranial pressure. DIF: Cognitive Level: Comprehension REF: p. 497 OBJ: 8 TOP: Prevention of Pneumonia KEY: Nursing Process Step: Implementation

25. The wife of a husband who has had a CVA asks why he is being treated with insulin since he has no history of diabetes. What is the best response by the nurse as to why hyperglycemia occurs after a stroke? a. Brain swelling b. Hypertension c. Immobility d. Stress

ANS: D Hyperglycemia occurs after a CVA as the body's response to stress. If left untreated, the hyperglycemia will cause increased brain damage and worsen the outcome of the stroke. DIF: Cognitive Level: Comprehension REF: p. 492 OBJ: 3 TOP: Hyperglycemia KEY: Nursing Process Step: Implementation

2. Which patient is at the greatest risk for a CVA? a. A 20-year-old obese Latin woman who is taking birth control pills b. A 40-year-old athletic white man with a family history of CVA c. A 60-year-old Asian woman who smokes occasionally d. A 65-year-old African American man with hypertension

ANS: D Older African Americans have a higher incidence of CVA than occasional smokers, young persons, or athletes. Hypertension increases the risk. DIF: Cognitive Level: Analysis REF: p. 483 OBJ: 1 TOP: CVA Risk Factors KEY: Nursing Process Step: Assessment

22. A patient in the rehabilitation phase after a CVA accidentally knocks the adapted plate from the table and bursts into tears after failing to feed himself. What is the best response by the nurse? a. "Don't cry. You'll be mastering eating in no time." b. "I don't believe crying will help. Let's try drinking from a special cup." c. "Bless your heart! Let me get a new meal and feed you." d. "Learning new skills is hard. Let's see what may have caused the trouble."

ANS: D Recognizing effort and showing support are the best approaches to depression and frustration. Babying the patient and admonitions against crying add to the problem. Redirection to the task at hand is therapeutic. DIF: Cognitive Level: Application REF: p. 504 OBJ: 8 TOP: Rehabilitation: Coping KEY: Nursing Process Step: Implementation

8. When should a nurse recognize that the acute phase of a CVA has ended? a. Forty-eight hours has passed from its onset. b. The patient begins to respond verbally. c. BP drops. d. Vital signs and neurologic signs stabilize.

ANS: D When the vital and neurologic signs stabilize, the acute phase has ended. Verbal response, lower BP, and the passage of time without other signs are not adequate evidence that the acute phase has ended. DIF: Cognitive Level: Comprehension REF: p. 491 OBJ: 7 TOP: Acute Phase of CVA KEY: Nursing Process Step: Assessment

28. What signs and symptoms characterize expressive aphasia? (Select all that apply.) a. Speech that sounds normal but makes no sense b. Total inability to communicate c. Difficulty understanding the written and spoken word d. Stuttering and spitting e. Difficulty initiating speech

ANS: E Expressive aphasia makes it difficult for the patient to initiate speech. DIF: Cognitive Level: Knowledge REF: p. 489-490 OBJ: 3 TOP: Expressive Aphasia KEY: Nursing Process Step: Implementation