Exam 1 Stroke Lippincott practice questions

What order of interventions from first to last should the nurse follow when suctioning the client to prevent increased intracranial pressure and maintain adequate cerebral perfusion?

1. Provide sedation 2. Hyperoxygenate- to prevent hypoxia 3. Suction the airway (No more than 10 seconds) 4. Suction the mouth

Which outcomes indicate effective management of a conscious client who is being treated with recombinant tissue plasminogen therapy during the initial phase of an ischemic cerebrovascular accident select all that apply A. Headache reduced B. Dysphasia improved C. Visual disturbances improved D. Responds to comfort measures E. No signs or symptoms of bleeding

A, D, E

A nurse is teaching a client who had a stroke about ways to adapt to visual disability. Which does the nurse identify as the primary safety precaution to use? A. Wear a patch over one eye B. Place personal items on the sighted side C. Lie in bed with the unaffected side toward the door D. Turn the head from side to side when walking

D.

The nurse is assisting a client with a stroke who has homonymous hemianopia. The nurse should understand that the client will do which when eating? A. Have a preference for foods high in salt B. Eat food on only half of the plate C. Forget the names of foods D. Be unable to swallow liquids

B- homonymous hemianopia is blindness in half of the visual field therefore the client would only see half of the plate

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

B. -To indicate changes around the cranial nerves

A client admitted with possible ischemic stroke has been aphasic for three hours and has a blood pressure of 220/120 mm hg which prescription by the healthcare provider should the nurse question? A. Labetalol drip to keep the blood pressure less than 120/80 B. Tissue plasminogen activator per protocol C. Normal saline intravenously at 75 mL per hour D. Bed elevated 30°

A - not recommended that diastolic blood pressure is less than 90 MMHG

The nurse is planning the care of a hemiplegic client to prevent joint deformities of the arm and hand which position is appropriate select all that apply A. Placing a pillow in the axilla so the arm is away from the body B. Inserting a pillow under the slightly flexed arm so the hand is higher than the elbow C. Immobilizing the extremity in a sling D. Positioning a hand cone in the hand so the fingers are barely flexed E. Keeping the arm at the side using a pillow

A, B D

The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which strategies should the nurse include in the teaching plan? Select all that apply A. Maintain an upright position while eating 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 E. Cutting food into large pieces of finger food

A,C,D

When communicating with a client who has aphasia which approaches are helpful select all that apply A. Present one thought at a time B. Avoid writing messages C. Speak with normal volume D. Make use of gestures E. Encourage pointing to the needed object

A,C,D,E

The nurse is observing the unlicensed assistive personnel give mouth care to a client who has had a stroke and is unconscious. The nurse should intervene if the UAP does which? A. Positions the client on the back with a small pillow under the head B. Keeps portable suction equipment at the bedside C. Opens the clients mouth with a padded tongue blade D. Cleans the clients mouth and teeth with a toothbrush

A- The UAP should position an unconscious client on the side, NOT on the back, with the head on a small pillow. A lateral position helps secretions escape from the throat and mouth minimizing the risk of aspiration

Which positioning technique is most effective when there is only one person to assist the client to move from the left side to the right side if the client has hemiparalysis ? A. Rolling the client onto the side B. Sliding the client to move up in the bed C. Lifting the client when moving the client up in bed D.Having the client help lift off the bed using a trapeze

A.

The nurse is teaching a client about taking prophylactic warfarin sodium. Which statement indicates that the client understands how to take the drug select all that apply A. The drugs action peaks in two hours B. Maximum dosage is not achieved until 3 to 4 days after starting the medication C. Effects of the drug continue for 4 to 5days after discontinuing the medication D. Protamine sulfate is the antidote for warfarin E. I should have my blood levels tested periodically

B, C, E

For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication? A. Speaking loudly and slowly B. Using a picture board for the client to point to pictures C. Writing direction so the client can read them D. Speaking in short sentences

B- expressive aphasia is a condition in which the client understands what is heard or written but cannot say what he or she wants to say therefore a communication or picture board helps the client communicate with others in that the client can point to objects or activities that he or she desires

A client arrives in the emergency department with an ischemic stroke. What should the nurse do before the client receives TPA? A. Ask which medications the client is taking B. Complete a history and health assessment C. Identify the time and onset of the stroke D. Determine if the client is scheduled for any surgical procedures

C

A client has received thrombolytic treatment for an ischemic stroke. The nurse should notify the healthcare provider if there is a rapid increase in which vital sign? A. Pulse B. Respirations C. Blood pressure D. Temperature

C

Following a stroke, a client has dysphagia and left-sided facial paralysis which feeding technique will be most helpful at this time? A.Encourage sipping diluted liquid meal supplements from a straw B. Position the client with the bed at 30° angle C. Offer solid foods from the unaffected side of the mouth. D. Feed the client a soft diet from a spoon into the left side of the mouth

C

Which is the most effective means of preventing plantar flexion in a client who has had a stroke with residual paralysis? A. Place the client speed again stay firm footboard B. Reposition the client every two hours C. Have the client wear ankle high tennis shoes at intervals throughout the day D.Massage the clients feet and ankles regularly

C-The use of ankle high tennis shoes has been found to be most effective in preventing plantar flexion because they add support to the foot and keep it in the correct anatomic position

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

C-Thrombolytic enzyme agents are used for clients with a thrombotic stroke to dissolve emboli reestablishing cerebral perfusion

A client is experiencing mood swings after stroke 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 clients attention D. Tell the client that this behavior is unacceptable

C. Divert the clients attention