Chapter 38

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 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 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 the past month B) No bowel movement since yesterday C) Nausea D) Frequent voiding

C) Nausea

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 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.

C) Avoid caffeine and alcohol.

A client who has experienced an initial transient ischemic attack (TIA) states: "I'm glad it wasn't anything serious."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) "TIA is a warning sign. Let's talk about lowering your risks."

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

D) "Your physician wants to evaluate the location and condition of the aneurysm."

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 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 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 priority 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

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

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 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

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.

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) Impaired muscle coordination B) Respiratory distress C) Severe headache D) Nausea and vomiting

A) Impaired muscle coordination

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 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 flashing light E) Change in environmental temperature F) Prolonged positioning

A) Red wine C) Menstruation D) Exposure to flashing light

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

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) "I use this to prevent migraines." B) "I take this when I get a headache." C) "It constricts the blood vessels in my head." D) "It alleviates my sensitivity to light and sound."

A) "I use this to prevent migraines."

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 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.

Which nursing assessment finding is the most indicative of a hemorrhage 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

A diagnostic test 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 electrolyte imbalance C) Impaired swallowing D) Altered nutrition: less than body requirements

C) Impaired swallowing

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.