Chapter 62 Prepu

impaired cerebral circulation

A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the health care provider in the emergency department. Which is the origin of the client's symptoms?

severe exploding headache

A client admitted to the emergency department is being evaluated for the possibility of a stroke. Which assessment finding would lead the nurse to suspect that the client is experiencing a hemorrhagic stroke?

Elevating the head of the bed to 30 degrees

After a stroke, a client is admitted to the facility. The client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g. Which nursing intervention is a priority for this client?

Diastolic pressure of 110 mm Hg

After the patient has received tPA, the nurse knows to check vital signs every 30 minutes for 6 hours. Which of the following readings would require calling the provider?

Every 15 minutes

How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tPA)?

Left visual field deficit

What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke?

Atrial fibrillation

Which of the following, if left untreated, can lead to an ischemic stroke?

Encourage the client to repeat sounds of the alphabet

Which statement reflects nursing management of the client with expressive aphasia?

Homonymous hemianopsia

Which term refers to blindness in the right or left half of the visual field in both eyes?

Agnosia

Which term refers to the failure to recognize familiar objects perceived by the senses?

Form words that are understandable or comprehend spoken words

A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to perform which action?

Call the physician immediately.

A nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform?

Noncontrast computed tomogram

A patient is brought to the emergency department with a possible stroke. What initial diagnostic test for a stroke, usually performed in the emergency department, would the nurse prepare the patient for?

Severe headache

A patient is exhibiting classic signs of a hemorrhagic stroke. What complaint from the patient would be an indicator of this type of stroke?

1 to 3 days

A patient is in the acute phase of an ischemic stroke. How long does the nurse know that this phase may last?

Semi-Fowler's

The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient?

Smoking

The nurse is participating in a health fair for stroke prevention. Which will the nurse say is a modifiable risk factor for ischemic stroke?

1 hour

The nurse knows that symptoms associated with a TIA, usually a precursor of a future stroke, usually subside in what period of time?

Uncontrolled hypertension

Which of the following is the chief cause of intracerebral hemorrhage (ICH)?

Bleeding

Which of the following is the most common side effect of tissue plasminogen activator (tPA)?

Carotid endarterectomy

A 76-year-old 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?

Limited attention span and forgetfulness

A client has experienced an ischemic stroke that has damaged the frontal lobe of his brain. Which of the following deficits does the nurse expect to observe during assessment?

Lack of deep tendon reflexes

A client has experienced an ischemic stroke that has damaged the lower motor neurons of the brain. Which of the following deficits would the nurse expect during assessment?

Relaxes muscles

A client has tension headaches. The nurse recommends massage as a treatment for tension headaches. How does massage help clients with tension headaches?

Left-sided cerebrovascular accident (CVA)

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?

Brain CT scan or MRI

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?

Help the client sit upright when eating and feed slowly

A client is experiencing dysphagia following a stroke. Which measure may be taken by the nurse to ensure that the client's diet allows for easy swallowing?

Codeine

A client is experiencing severe pain related to increased ICP. Which analgesic would be ordered for this client to help alleviate pain?

Transient ischemic attack

A client is hospitalized when presenting to the emergency department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to his presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what?

Increased urine output

A client is receiving an IV infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To confirm that this drug is producing its therapeutic effect, the nurse should consider which finding most significant?

Restrict fluids before surgery.

A client on your unit is scheduled to have intracranial surgery in the morning. Which nursing intervention helps to avoid intraoperative complications, reduce cerebral edema, and prevent postoperative vomiting?

The client is unaware of his left side. You should approach him on the right side."

A client recently experienced a stroke with accompanying left-sided paralysis. His family voices concerns about how to best interact with him. They report the client doesn't seem aware of their presence when they approach him on his left side. What advice should the nurse give the family?

Bruit

A client reports light-headedness, speech disturbance, and left-sided weakness that have lasted for several hours. In the examination, an abnormal sound is auscultated in an artery leading to the brain. What is the term for the auscultated discovery?

Hemiplegia, seizures, and decreased level of consciousness

A client undergoes cerebral angiography for evaluation of a subarachnoid hemorrhage. Which findings indicate spasm or occlusion of a cerebral vessel by a clot?

The client uses a mirror to inspect the skin.

A client who's paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis?

Immediately

A client's spouse relates how the client reported a severe headache and then was unable to talk or move their right arm and leg. After diagnostics are completed and the client is admitted to the hospital, when would basic rehabilitation begin?

Impaired Swallowing

A diagnostic test has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include thickened liquids. Which of the following is the priority nursing diagnosis for this client?

Migraines often coincide with menstrual cycle

A female client who reports 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?

Heparin sodium

A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question?

Spouse

A nurse in a rehabilitation facility is coordinating the discharge of a client who is tetraplegic. The client, who is married and has two children in high school, is being discharged to home and will require much assistance. Who would the discharge planner recognize as being the most important member of this client's care team?

Report changes in neurologic status as soon as a worsening trend is identified. Maintain the head of the bed at 30 degrees. Avoid any activities that cause a Valsalva maneuver.

A nurse is caring for a client with a cerebral aneurysm. Which nursing interventions would be most useful to the nurse to avoid bleeding in the brain? Select all that apply.

Risk for injury

A nurse is completing discharge teaching for the client who has left-sided hemiparesis following a stroke. When investigating the client's home environment, the nurse should focus on which nursing diagnosis?

"Emotional lability is common after a stroke, and it usually improves with time."

A nurse is instructing the spouse of a client who suffered a stroke about the use of eating devices the client will be using. During the teaching, the spouse starts to cry and states, "One minute he is laughing, and the next he's crying; I just don't understand what's wrong with him." Which statement is the best response by the nurse?

cardio embolic

A nurse is reading a journal article about stroke and the underlying causes associated with this condition. The nurse demonstrates understanding of the information when identifying which subtype of stroke as being due to atrial fibrillation?

Thrombolytic therapy has a time window of only 3 hours.

A nurse is teaching a community class that those experiencing symptoms of ischemic stroke need to enter the medical system early. The primary reason for this is which of the following?

Advanced age

A nurse is teaching a community group about modifiable and nonmodifiable risk factors for ischemic strokes. Which of the following is a risk factor that cannot be modified?

Keeping the client in one position to decrease bleeding

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention

Tissue plasminogen activator (tPA)

A patient diagnosed with an ischemic stroke should be treated within the first 3 hours of symptom onset with which of the following?

A thrombus formation at the site of the endarterectomy

A patient had a carotid endarterectomy yesterday and when the nurse arrived in the room to perform an assessment, the patient states, "All of a sudden, I am having trouble moving my right side." What concern should the nurse have about this complaint?

This is significant for poor neurologic outcomes.

A patient having an acute stroke with no other significant medical disorders has a blood glucose level of 420 mg/dL. What significance does the hyperglycemia have for this patient?

4:00 p.m. (must be given within 3 hr)

A patient is admitted via ambulance to the emergency room of a stroke center at 1:30 p.m. with symptoms that the patient said began at 1:00 p.m. Within 1 hour, an ischemic stroke had been confirmed and the doctor ordered tPA. The nurse knows to give this drug no later than what time?

Cerebral aneurysm

A patient presents to the emergency room with complaints of having an "exploding headache" for the last 2 hours. The patient is immediately seen by a triage nurse who suspects the patient is experiencing a stroke. Which of the following is a possible cause based on the characteristic symptom?

Lioresal (Baclofen)

A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem?

Frontal

A stroke victim is experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe?

3 hours

An emergency department nurse is awaiting the arrival of a client with signs of an ischemic stroke that began 1 hour ago, as reported by emergency medical personnel. The treatment window for thrombolytic therapy is which of the following?

International normalized ratio greater than 2 (risk for bleeding)

An emergency department nurse is interviewing a client who is presenting with signs of an ischemic stroke that began 2 hours ago. The client reports a history of a cholecystectomy 6 weeks ago and is taking digoxin, warfarin, and labetalol. What factor poses a threat to the client for thrombolytic therapy?

"Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation."

During a class on stroke, a junior nursing student asks what the clinical manifestations of stroke are. What would be the instructor's best answer?

From the left side of the client

From which direction should a nurse approach a client who is blind in the right eye?

Aspirin

If warfarin is contraindicated as a treatment for stroke, which medication is the best option?

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

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?

Remove throw rugs and electrical cords from home environment.

The geriatric advanced practice nurse (APN) is doing client teaching with a client who has had a cerebrovascular accident (CVA) and the client's family. One concern the APN addresses is a potential for falls related to the CVA and resulting muscle weakness. What would be most important for the APN to include in teaching related to this concern?

Spatial-perceptual deficits

The nurse has just received report on a client in the ED being transferred to the acute stroke unit with a diagnosis of a right hemispheric stroke. Which findings does the nurse understand is indicative of a right hemispheric stroke?

Ischemic

The nurse is caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke does the nurse know this client has?

Maintaining a patent airway

The nurse is caring for a client diagnosed with a hemorrhagic stroke. The nurse recognizes which intervention is most important ?

Psychosis, disorientation, delirium, insomnia, and hallucinations

The nurse is caring for a client following an aneurysm coiling procedure. The nurse documents that the client is experiencing Korsakoff syndrome. Which set of symptoms characterizes Korsakoff syndrome?

Severe unilateral headache

The nurse is caring for a client recovering from a carotid endarterectomy. Which finding indicates to the nurse that the client is experiencing hyperperfusion syndrome?

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

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 who has an aneurysm?

Difficulty swallowing

The nurse is caring for a client with a history of transient ischemic attacks (TIAs) and moderate carotid stenosis who has undergone a carotid endarterectomy. Which postoperative finding would cause the nurse the most concern?

Establishing eye contact

The nurse is caring for a client with aphasia. Which strategy will the nurse use to facilitate communication with the client?

Placing food on the affected side of the mouth

The nurse is caring for a client with dysphagia. Which intervention would be contraindicated while caring for this client?

Weakness on one side of the body and difficulty with speech

The nurse is providing information about strokes to a community group. Which of the following would the nurse identify as the primary initial symptoms of an ischemic stroke?

Hypertension

The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regimen, to maintain a healthy weight, and to adopt a reasonable exercise program. This advice is based on research data that shows the most important risk factor for stroke is:

Right-sided paralysis.

The nurse practitioner is able to correlate a patient's neurologic deficits with the location in the brain affected by ischemia or hemorrhage. For a patient with a left hemispheric stroke, the nurse would expect to see:

Cardiogenic emboli

The provider diagnoses the patient as having had an ischemic stroke. The etiology of an ischemic stroke would include which of the following?

3 hours

Thrombolytic therapy for the treatment of an ischemic stroke should be initiated within how many hours of the onset of symptoms to obtain the best functional outcome

use short, simple sentences

When communicating with a client who has sensory (receptive) aphasia, the nurse should:

The stroke may have impacted the body's thermoregulatory centers

When developing a care plan for a client who has recently suffered a stroke, a nurse includes the nursing diagnosis Risk for imbalanced body temperature. What is the rationale for this diagnosis?

The day the patient has the stroke

When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke?

Neglect of the left side

Which clinical manifestation would be exhibited by a client following a hemorrhagic stroke of the right hemisphere?

Intracranial hemorrhage

Which is a contraindication for the administration of tissue plasminogen activator (t-PA)?

Noncontrast computed tomography

Which is the initial diagnostic test for a stroke?

Hemiplegia

Which is the most common motor dysfunction seen in clients diagnosed with stroke?

Main presenting symptom is an "exploding headache."

Which of the following is accurate regarding a hemorrhagic stroke?

Apraxia

Which term refers to the inability to perform previously learned purposeful motor acts on a voluntary basis?

Complications.

While caring for clients who have suffered neurologic deficits from causes such as cerebrovascular accident and closed head injury, an important nursing goal that motivates nurses to offer the best care possible is preventing:

Severe headache and early change in level of consciousness

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are: