PrepU Ch. 67- CVD
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 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?
"TIA is a warning sign. Let's talk about lowering your risks."
A client with hypercholesterolemia is receiving Lipitor (atorvastatin) to prevent high cholesterol and stroke. The order is for Lipitor 40 mg PO daily. The medication is supplied in 80 mg tabs. How many tabs will the nurse administer to the client? Enter the correct number ONLY.
0.5
Which of the following terms refer to the failure to recognize familiar objects perceived by the senses?
Agnosia
A 64-year-old client has an appointment with a physician within the neurology group where you practice nursing. The client is following up after a visit to the emergency department where testing indicated that he had suffered a transient ischemic attack. To prevent the occurrence of a more serious cerebrovascular accident, which of the following recommendations for lifestyle changes would you expect the neurologist to prescribe?
All options are correct.
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 medical treatment to include which of the following?
Anticoagulant therapy
Following the use of a thrombolytic agent in the management of cerebrovascular accident (CVA) client, which is the priority nursing assessment?
Blood pressure
A 73-year-old client is visiting the neurologist. The 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
The nurse is caring for a patient with a history of transient ischemic attacks (TIAs) and moderate carotid stenosis who has undergone a carotid endarterectomy. Which of the following postoperative findings would cause the nurse the most concern?
Difficulty swallowing
The nurse is caring for a patient with aphasia. Which of the following strategies will the nurse use to facilitate communication with the patient?
Establishing eye contact
How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tPA)?
Every 15 minutes
From which direction should a nurse approach a client who is blind in the right eye?
From the left side of the client
The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regime, 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:
Hypertension
Which of the following is a contraindication for the administration of tissue plasminogen activator (t-PA)?
Intracranial hemorrhage
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?
Ischemic
What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke?
Left visual field deficit
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
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 of the client and family related to this concern?
Remove throw rugs and electrical cords from home environment.
You are caring for a client with chronic migraines who is prescribed medication. What drug-related instructions should the nurse give the client?
Take medication as soon as symptoms of the migraine begin.
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 stroke may have impacted the body's thermoregulation centers.
Which of the following goals is the priority in the care planning of a client with cerebrovascular accident (CVA) who is being transferred to a rehabilitation unit?
To prevent contractures and joint deformities
When communicating with a client who has sensory (receptive) aphasia, the nurse should:
use short, simple sentences.
The nurse is taking care of a client with a headache. In addition to administering medications, the nurse takes measures to assist the client in reducing the pain associated with his headache. Which of the following appropriate nursing interventions may be provided by the nurse to assist this client in reducing or eliminating his pain?
Apply warm or cool cloths to the forehead or back of the neck.
A patient has been diagnosed as having global aphasia. The nurse recognizes that the patient will be unable to do which of the following actions?
Form words that are understandable or comprehend the spoken word
A physician orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question?
Heparin sodium
Which disturbance results in loss of half of the visual field?
Homonymous hemianopsia
Which of the following terms refers to blindness in the right or left halves of the visual fields of both eyes?
Homonymous hemianopsia
A patient is suspected of having had a stroke. Which of the following is the initial diagnostic test for a stroke?
Noncontrast CT scan
The nurse is providing diet-related advice to a male patient following a cerebrovascular accident (CVA). The patient wants to minimize the volume of food and yet meet all nutritional elements. Which of the following suggestions should the nurse give to the patient about controlling the volume of food intake?
Provide thickened commercial beverages and fortified cooked cereals.
The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient?
Semi-Fowler's
A patient is exhibiting classic signs of a hemorrhagic stroke. What complaint from the patient would be an indicator of this type of stroke?
Severe headache
An emergency department nurse is interviewing a client with signs of an ischemic stroke that began 2 hours ago. The client reports that she had a cholecystectomy 6 weeks ago and is taking digoxin, coumadin, and labetelol. This client is not eligible for thrombolytic therapy for which of the following reasons?
She is taking coumadin.
Which of the following is indicative of a right hemisphere stroke?
Spatial-perceptual deficits
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?
4:00 p.m.
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 client with atrial fibrillation is placed on Coumadin to reduce the potential of developing a cerebrovascular accident (CVA). The international normalized ratio (INR) is 1.5. What does this finding indicate to the nurse?
Coumadin will be increased.
A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take?
Face the client and establish eye contact.
A client undergoes cerebral angiography for evaluation after an intracranial computed tomography scan revealed a subarachnoid hemorrhage. Afterward, the nurse checks frequently for signs and symptoms of complications associated with this procedure. Which findings indicate spasm or occlusion of a cerebral vessel by a clot?
Hemiplegia, seizures, and decreased level of consciousness (LOC)
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)
Which of the following is accurate regarding a hemorrhagic stroke?
Main presenting symptom is an "exploding headache."
The nurse is caring for a patient diagnosed with a hemorrhagic stroke. The nurse recognizes that which of the following interventions is most important?
Maintaining a patent airway
Which of the following clinical manifestations would be exhibited by a patient following a hemorrhagic stroke of the right hemisphere?
Neglect of the left side
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?
Lioresal (Baclofen)
A nurse is assisting with a community screening for people at high risk for stroke. To which of the following clients would the nurse pay most attention?
A 60-year-old African-American man
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?
A thrombus formation at the site of the endarterectomy
The provider diagnoses the patient as having had an ischemic stroke. The etiology of an ischemic stroke would include which of the following?
Cardiogenic emboli
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.
A patient diagnosed with an ischemic stroke should be treated within the first 3 hours of symptom onset with which of the following?
Tissue plasminogen activator (tPA)
A client is hospitalized when they present 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 their presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what?
Transient ischemic attack
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 nurse is caring for a patient with dysphagia. Which of the following interventions would be contraindicated while caring for this patient?
Placing food on the affected side of mouth
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.
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?
Risk for injury
A client is receiving an I.V. infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant?
Increased urine output
Which of the following is the initial diagnostic test for a stroke?
Noncontrast CT scan
