N140 chapter 67

Which interventions would be recommended for a client with dysphagia? Select all that apply.

Allow ample time to eat. Test the gag reflex before offering food or fluids. Assist the client with meals.

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?

Anticoagulant therapy

A nurse is caring for a client who has returned to his room after a carotid endarterectomy. Which action should the nurse take first?

Ask the client if he has trouble breathing.

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?

Bruit

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?

Diastolic pressure of 110 mm Hg

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?

Difficulty swallowing

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

Encourage the client to repeat sounds of the alphabet

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

Establishing eye contact

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

Form words that are understandable or comprehend spoken words

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?

Lack of deep tendon reflexes

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?

Left-sided cerebrovascular accident (CVA)

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?

Limited attention span and forgetfulness

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

Neglect of the left side

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?

Noncontrast computed tomogram

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?

Remove throw rugs and electrical cords from home environment.

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:

Right-sided paralysis.

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

Severe headache and early change in level of consciousness

What nursing intervention is appropriate for a client with receptive aphasia?

Speak slowly and clearly.

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?

Three 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?

Thrombolytic therapy has a time window of only 3 hours.

Which of the following diagnostics are beneficial to detect intracranial stenosis?

Transcranial Doppler (TCD)

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

bleeding

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?

cardio embolic

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?

cerebral aneurysm

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

frontal

A client is admitted for evaluation of cerebral aneurysm. Which assessment finding is of greatest importance in prioritizing nursing care to this client?

nausea

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?

severe exploding headache

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

smoking

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?

"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."

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?

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

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?

Impaired Swallowing

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?

Increased urine output

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?

International normalized ratio greater than 2

A client is brought to the emergency department in a confused state, with slurred speech, characteristics of a headache, and right facial droop. The vital signs reveal a blood pressure of 170/88 mm Hg, pulse of 92 beats/minute, and respirations at 24 breaths/minute. On which bodily system does the nurse focus the nursing assessment?

Neurovascular system

A male patient with cerebrovascular accident (CVA) is prescribed medication to treat the disorder. The patient wants to know what other measures may help reduce CVA. Which of the following is an accurate suggestion for the patient?

Reduce hypertension and high blood cholesterol levels.

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?

immediately

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?

impaired cerebral circulation

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

Hemiplegia, seizures, and decreased level of consciousness

Which disturbance results in loss of half of the visual field?

Homonymous hemianopsia

A client with a cerebrovascular accident (CVA) is having difficulty with eating food on the plate. Which is the best priority nursing action to be taken?

Perform a vision field assessment.

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

Placing food on the affected side of the mouth

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?

Spouse

A client reports light-headedness, speech disturbance, and left-sided weakness lasting for several hours. The neurologist diagnosed a transient ischemic attack, which caused the client great concern. What would the nurse include during client education?

When symptoms cease, the client will return to presymptomatic state.

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

apraxia

A client diagnosed with a stroke is ordered to receive warfarin. Later, the nurse learns that the warfarin is contraindicated and the order is canceled. The nurse knows that the best alternative medication to give is

aspirin.