week 6 PrepU 280

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?

A ruptured intracranial aneurysm must quickly be repaired. Thrombolytic therapy has a time window of only 3 hours. A ruptured arteriovenous malformation will cause deficits until it is stopped. Intracranial pressure is increased by a space-occupying bleed.

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

Advanced age Social drinking Smoking Thyroid disease

Which term refers to the failure to recognize familiar objects perceived by the senses?

Agnosia Agraphia Perseveration Apraxia

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?

Auditory agnosia Visual agnosia Limited attention span and forgetfulness Lack of deep tendon reflexes

A family member brings a 76-year-old client to the clinic, stating that the client has had two transient ischemic attacks (TIAs) in the past week. The health care provider orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option(s) does the nurse expect the health care provider to offer this client to increase blood flow to the brain? Select all that apply.

Carotid endarterectomy Percutaneous transluminal coronary artery angioplasty Balloon angioplasty of the carotid artery followed by stent placement Removal of the carotid artery Administration of tissue plasminogen activator

If warfarin is contraindicated as a treatment for stroke, which medication is the best option?

Clopidogrel Ticlodipine Dipyridamole aspirin

A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question?

Dexamethasone Methyldopa Phenytoin Heparin sodium

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 Temporal Parietal Occipital

The nurse is caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke does the nurse know this client has?

Ischemic Hemorrhagic Right-sided Left-sided

Which of the following is accurate regarding a hemorrhagic stroke?

Main presenting symptom is an "exploding headache." It is caused by a large-artery thrombosis. One of the main presenting symptoms is numbness or weakness of the face. Functional recovery usually plateaus at 6 months.

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?

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

A community health nurse is conducting a workshop for unlicensed care providers who work in a chain of long-term care facilities. The nurse is teaching the participants about the signs and symptoms of stroke. What signs and symptoms should the nurse identify? Select all that apply.

Visual disturbances Confusion Sudden numbness Sudden ear pain Epistaxis (nosebleed)

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

Weakness on one side of the body and difficulty with speech Severe headache and early change in level of consciousness Foot drop and external hip rotation Confusion or change in mental status

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 cardiac disease hypertension diabetes insipidus

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. A decreased body temperature will signal the need to cover the client. An elevated temperature indicates cerebellum malfunction. An elevated body temperature indicates infection.

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 how quickly the clot can be dissolved." "Clinical manifestations of a stroke are highly variable, depending on the cardiovascular health of the client." "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." "Clinical manifestations of a stroke generally include aphasia, one-sided flaccidity, and trouble swallowing."

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?

2:00 p.m. 3:00 p.m. 4:00 p.m. 7:00 p.m.

The nurse is preparing to administer tissue plasminogen activator (t-PA) to a patient who weighs 132 lb. The order reads 0.9 mg/kg t-PA. The nurse understands that 10% of the calculated dose is administered as an IV bolus over 1 minute, and the remaining dose (90%) is administered IV over 1 hour via an infusion pump. How many milligrams IV bolus over 1 minute will the nurse initially administer?

5.4mg

A 154-pound woman has been prescribed tPA (0.9 mg/kg) for an ischemic stroke. The nurse knows to give how many mg initially?

7.5 mg 8.3 mg 10 mg 6.3 mg

A nurse who provides care at a community clinic is in contact with a diverse group of patients. Which of the following individuals most clearly displays risk factors for stroke?

A man who is receiving oral antibiotics for the treatment of a chlamydial infection An obese woman with a history of atrial fibrillation and type 2 diabetes A 70-year-old man who has benign prostatic hyperplasia and early stage Alzheimer's disease A woman who has osteoporosis, a history of fractures, and a family history of stroke

What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke?

Aphasia Altered intellectual ability Slow, cautious behavior Left visual field deficit

The nurse is taking care of a client with a headache. In addition to administering medications, the nurse takes which measure to assist the client in reducing the pain associated with the headache?

Apply warm or cool cloths to the forehead or back of the neck. Use pressure-relieving pads or a similar type of mattress. Perform the Heimlich maneuver. Encouraging the client to drink eight glasses of fluid a day.

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

Difficulty breathing or swallowing Nausea, vomiting, and profuse sweating Hemiplegia, seizures, and decreased level of consciousness Tachycardia, tachypnea, and hypotension

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?

Diphenhydramine (Benadryl) Heparin Lioresal (Baclofen) Pregabalin (Lyrica)

The nurse is caring for a client who has had a cerebrovascular accident. The client has a nursing diagnosis of altered nutritional status related to difficulty swallowing. What intervention would it be important for the nurse to institute?

Encourage the client to eat semisolid foods and cold foods. Encourage the client to drink hot liquids. Encourage the client to eat tepid foods. Encourage the client to eat solid foods.

Which term will the nurse use when referring to blindness in the right or left half of the visual field in both eyes?

Homonymous hemianopsia Nystagmus Diplopia Scotoma

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

Hypertension Headache Increased intracranial pressure (ICP) Bleeding

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 Decreased heart rate Decreased level of consciousness (LOC) Elevated blood pressure

A client is suspected of having had a stroke. Which is the initial diagnostic test for a stroke?

Noncontrast computed tomography Carotid Doppler Electrocardiography Transcranial Doppler studies

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention?

Positioning the client to prevent airway obstruction Maintaining the client in a quiet environment Keeping the client in one position to decrease bleeding Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess

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. Impulsive behavior. Left visual field deficit. Spatial-perceptual deficits.

A client tells the nurse that they have transient ischemic attacks. The client reports having undergone a carotid artery surgery. In such a case, what important assessments should be performed by the nurse?

Sexual history Frequent neurologic checks Motor and sensory responses Blood pressure and weight

Which of the following statements reflects nursing management of the patient with expressive aphasia?

Speak clearly and in simple sentences; use gestures or pictures when able. Frequently reorient the patient to time, place, and situation. Speak slowly and clearly to assist the patient in forming the sounds. Encourage the patient 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?

Speaking in complete sentences Establishing eye contact Speaking loudly Avoiding the use of hand gestures

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?

Surgery 6 weeks ago Two hour time period of the stroke International normalized ratio greater than 2 Taking digoxin

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?

Surgical wound infection This is a normal occurrence after an endarterectomy and would not be a concern. Bleeding from the endarterectomy site A thrombus formation at the site of the endarterectomy

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?

Symptoms of a TIA may linger for up to a week. A TIA is an insidious, often chronic episode of neurologic impairment. Two thirds of people that experience a TIA will go on to develop a stroke. When symptoms cease, the client will return to presymptomatic state.

Which is a contraindication for the administration of tissue plasminogen activator (t-PA)?

Systolic blood pressure less than or equal to 185 mm Hg Intracranial hemorrhage Ischemic stroke Age 18 years or older

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

Test the gag reflex before offering food or fluids. Place food on the affected side of the mouth. Allow ample time to eat. Assist the client with meals.

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 Two hours Six hours One hour

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?

diplopia atherosclerotic plaque TIA bruit