PUCH62CerebrovascularDisorders PartI

A 45-year-old client presents to the ED reporting trouble speaking and numbness of the right arm and leg. The nurse suspects an ischemic stroke. Which insult or abnormality can cause an ischemic stroke? A. Cocaine use B. Arteriovenous malformation C. Trauma D. Intracerebral aneurysm rupture

A

A client is experiencing severe pain related to increased ICP. Which analgesic would be ordered for this client to help alleviate pain? A. codeine B. hydrocodone C. morphine D. fentanyl

A

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? A. Restrict fluids before surgery. B. Administer prescribed medications. C. Administer preoperative sedation. D. Administer an osmotic diuretic.

A

The nurse is caring for a client with aphasia. Which action will the nurse take when communicating with the client? Select all that apply. A. Pause between phrases B. Use gestures when talking C. Face the client when talking D. Talk over the television volume E. Speak in a normal tone of voice

A B C E

The nurse plays a critical role in the initial work-up of a patient with acute stroke symptoms. An immediate decision is to determine if the stroke is ischemic or hemorrhagic. Although there is overlap in some motor, sensory, and cognitive changes, hemorrhagic strokes can be identified by some specific signs. Which of the following signs are consistent with a hemorrhagic stroke? Select all that apply. A. Vomiting B. Numbness or weakness of an extremity C. Sudden, severe headache D. Loss of balance E. Seizures

A C E

If warfarin is contraindicated as a treatment for stroke, which medication is the best option? A. Dipyridamole B. Aspirin C. Clopidogrel D. Ticlodipine

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 patient is in the acute phase of an ischemic stroke. How long does the nurse know that this phase may last? A. Up to 2 weeks B. Up to 1 week C. 1 to 3 days D. Up to 24 hours

C

Which is the most common motor dysfunction seen in clients diagnosed with stroke? A. Ataxia B. Diplopia C. Hemiplegia D. Hemiparesis

C

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? A. Checking stools for occult blood B. Performing range-of-motion (ROM) exercises on the left side C. Keeping skin clean and dry D. Elevating the head of the bed to 30 degrees

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

When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke? A. The day before the patient is discharged B. After the patient has passed the acute phase of the stroke C. After the nurse has received the discharge orders D. The day the patient has the stroke

D

Which term refers to the inability to perform previously learned purposeful motor acts on a voluntary basis? A. Agnosia B. Agraphia C. Perseveration D. Apraxia

D

Aneurysm rebleeding occurs most frequently during which time frame after the initial hemorrhage? A. First 12 hours B. First 24 hours C. First 48 hours D. First 72 hours

A

Aneurysm rebleeding occurs most frequently during which time frame after the initial hemorrhage? A. First 2 to 12 hours B. First 48 hours C. First week D. First 2 weeks

A

A nurse is caring for a client who has returned to his room after a carotid endarterectomy. Which action should the nurse take first? A. Ask the client if he has trouble breathing. B. Take the client's blood pressure. C. Ask the client if he has a headache. D. Place antiembolism stockings on the client.

A

An emergency department nurse understands that a 110-lb (50-kg) recent stroke victim will receive at least the minimum dose of recombinant tissue plasminogen activator (t-PA). What minimum dose will the client receive? A. 45 mg B. 50 mg C. 85 mg D. 90 mg

A

During the recovery phase of a neurologic deficit, assessment tools may be used to help identify a client's level of functioning. Which tool is used to measure performance in activities of daily living (ADL)? A. The Barthel Index B. The American Heart Association's Stroke Outcome Classification C. The National Institute for Health Stroke Scale D. Hamilton Assessment Scale

A

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? A. Psychosis, disorientation, delirium, insomnia, and hallucinations B. Severe dementia and myoclonus C. Tremor, rigidity, and bradykinesia D. Choreiform movement and dementia

A

The nurse knows that symptoms associated with a TIA, usually a precursor of a future stroke, usually subside in what period of time? A. 1 hour B. 3 to 6 hours C. 12 hours D. 24 to 36 hours

A

Which of the following diagnostics are beneficial to detect intracranial stenosis? A. Transcranial Doppler (TCD) B. Computed tomography (CT) C. CT with contrast D. Magnetic resonance imaging (MRI)

A

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. A. Report changes in neurologic status as soon as a worsening trend is identified. B. Use a well-lighted room for assessments every 2 hours. C. Follow the healthcare provider's orders to increase fluid volume. D. Maintain the head of the bed at 30 degrees. E. Avoid any activities that cause a Valsalva maneuver.

A D E

A nurse is caring for an older client who has had a hemorrhagic stroke. The client has exhibited impulsive behavior and, despite reminders from the nurse, doesn't recognize his limitations. Which priority measure should the nurse implement to prevent injury? A. Encourage the client to do as much as possible without assistance, and to use the call light only in emergencies. B. Install a bed alarm to remind the client to ask for assistance and to alert staff that the client is getting out of bed. C. Encourage the family to reprimand the client if he doesn't ask for help with transfers and mobility. D. Ask a physician to order a vest and wrist restraints.

B

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? A. Aphasia B. Spatial-perceptual deficits C. Slow, cautious behavior D. Altered intellectual ability

B

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? A. Difficulty breathing B. Decreased blood pressure C. Severe unilateral headache D. Change in vision in one eye

C

What nursing intervention is appropriate for a client with receptive aphasia? A. Encourage the client to repeat sounds of the alphabet. B. Explore the client's ability to write. C. Speak slowly and clearly. D. Frequently reorient the client to time, place, and situation.

C

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? A. "I sense that you are happy it was not a stroke". B. "People who experience a TIA will develop a stroke". C. "TIA symptoms are short-lived and resolve within 24 hours". D. "TIA is a warning sign. Let's talk about lowering your risks."

D