EXAM4: NEURO

A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the physician in the emergency department. What is the origin of the client's symptoms? A. impaired cerebral circulation B. cardiac disease C. diabetes insipidus D. hypertension

A

Nursing care during the immediate recovery period from an ischemic stroke should include which of the following? A. Positioning to avoid hypoxia B. Maximizing PaCO2 C. Administering hypertonic IV solution D. Initiating early mobilization

A

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? A. Weakness on one side of the body and difficulty with speech B. Severe headache and early change in level of consciousness C. Foot drop and external hip rotation D. Vomiting and seizures

A

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, B, E

Which is indicative of a right hemisphere stroke? A. Aphasia B. Spatial-perceptual deficits C. Slow, cautious behavior D. Altered intellectual ability

B

A client diagnosed with a stroke is having difficulty forming words during communication. This would be appropriately documented as A. dysphagia. B. receptive aphasia. C. dysarthria. D. diplopia.

C

A client who has experienced an ischemic stroke has been admitted to the medical unit. The client's family is adamant that she remain on bed rest to hasten her recovery and to conserve energy. What principle of care should inform the nurse's response to the family? A. The client should mobilize as soon as she is physically able. B. To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks. C. The client should remain on bed rest until she expresses a desire to mobilize. D. Lack of mobility will greatly increase the client's risk of stroke recurrence.

C

A community health nurse is giving an educational presentation about stroke and heart disease at the local senior citizens' center. What nonmodifiable risk factor for stroke should the nurse cite? A. Female gender B. Asian race C. Advanced age D. Smoking

C

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

A nurse is planning care for a client who experienced a stroke in the right hemisphere of his brain. What should the nurse do? A. Anticipate the client will exhibit some degree of expressive or receptive aphasia. B. Place the wheelchair on the client's left side when transferring him into a wheelchair. C. Provide close supervision because of the client's impulsiveness and poor judgment. D. Support the right arm with a sling or pillow to prevent subluxation.

C

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: A. Obesity B. Dyslipidemia C. Smoking D. Hypertension

D

What should be included in the client's care plan when establishing an exercise program for a client affected by a stroke? A. Schedule passive range of motion every other day. B. Keep activity limited, as the client may be overstimulated. C. Have the client perform active range-of-motion (ROM) exercises once a day. D. Exercise the affected extremities passively four or five times a day.

D

When communicating with a client who has sensory (receptive) aphasia, the nurse should: A. allow time for the client to respond. B. speak loudly and articulate clearly. C. give the client a writing pad. D. use short, simple sentences.

D