102 Exam 1
A nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform? A. Sit with the client for a few minutes. В. Administer an analgesic. C. Inform the nurse manager. D. Call the physician immediately. E. Call the stroke team
E. Call the stroke team
A client with atrial fibrillation is receiving coumadin to prevent clots from forming in the atria. The order is for Coumadin (warfarin) 2.5 mg orally daily. The medication is supplied in 1 mg tabs. How many tabs will the nurse administer to the client? Enter the correct number ONLY. A. 2.5 B. 2 C. 0.5 D. 1.5
A. 2.5
Thrombolytic therapy should be initiated within what time frame of an ischemic stroke to achieve the best functional outcome? A. 3 hours B. 6 hours C. 9 hours D. 12 hours
A. 3 hours
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. A thrombus formation at the site of the endarterectomy B. This is a normal occurrence after an endarterectomy and would not be a concern. C. Bleeding from the endarterectomy site D. Surgical wound infection
A. A thrombus formation at the site of the endarterectomy
How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tRA)? A. Every 15 minutes B. Every 30 minutes C. Every 45 minutes D. Every hour
A. Every 15 minutes
The nurse is assessing a client with a suspected stroke. What assessment finding is most suggestive of a stroke? Select all that apply. A. Facial droop B. Dysrhythmias C. Periorbital edema D. Projectile vomiting E. Loss of balance F. Weakness on one side
A. Facial droop E. Loss of balance F. Weakness on one side
Which disturbance results in loss of half of the visual field? A. Homonymous hemianopsia B. Diplopia C. Nystagmus D. Anisocoria
A. Homonymous hemianopsia
A nurse is providing education to a community group about ischemic strokes. One group member asks if there are ways to reduce the risk for stroke. Which of the following is a risk factor that can be modified? Select all that apply. A. Hypertension B. Advanced Age C. Male gender D. African heritage E. Carotid stenosis
A. Hypertension E. Carotid stenosis
The client has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the client's atmosphere more conducive to communication? A. Provide a board of commonly used needs and phrases. B. Have the client speak to loved ones on the phone daily. C. Help the client complete his or her sentences as needed. D. Speak in a loud and deliberate voice to the client.
A. Provide a board of commonly used needs and phrases.
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? A. severe exploding headache B. left-sided weakness C. slurred speech D. difficulty finding appropriate words
A. Severe exploding headache
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. Thrombolytic therapy has a time window of only 3 hours. B. A ruptured intracranial aneurysm must quickly be repaired. C. Intracranial pressure is increased by a space-occupying bleed. D. A ruptured arteriovenous malformation will cause deficits until it is stopped.
A. Thrombolytic therapy has a time window of only 3 hours.
A nurse is communicating with a client who has aphasia after having a stroke. Which action would the nurse take? Select all that apply. A. Use short phrases to communicate B. Keep the television on while she speaks. C. Talk in a louder than normal voice. D. Face the client and establish eye contact. E. Allow extra time for patient to process information
A. Use short phrases to communicate D. Face the client and establish eye contact. E. Allow extra time for patient to process information
A client recently experienced a stroke with accompanying left-sided paralysis. His family voices conces about how to best interact with him. They report the client doesn't seem aware of their presence when they approach him on his left side. What advice should the nurse give the family? A. "The client is feeling an emotional loss. He'll eventually start acknowledging you on his left side." B. "The client is unaware of his left side. You should approach him on the right side." C. "The client is unaware of his left side. You need to encourage him to interact from this side." D. "This condition is temporary."
B. "The client is unaware of his left side. You should approach him on the right side."
A rehabilitation nurse caring for a client who has had a stroke is approached by the client's family and asked why the client has to do so much for self-care while obviously struggling to do so. What would be the best answer? A. "We are trying to help the clients as useful as possible" B. "The focus on care in the rehabilitation facility is to help the client to resume as much self care as possible" C. "We are here to help the client get better and go home"
B. "The focus on care in the rehabilitation facility is to help the client to resume as much self care as possible"
The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration? A. Generalized pain B. Alteration in level of consciousness (LOC) C. Tonic-clonic seizures D. Shortness of breath
B. Alteration in level of consciousness
When caring for a client who has had a stroke, a priority is reduction of ICP. What client position is most consistent with this goal? A. Head turned slightly to the right side B. Elevation of the head of the bed C. Position changes every 15 minutes while awake A. Extension of the neck
B. Elevation of the head of the bed
A critical care nurse is caring for a client with a cerebrovascular accident (CVA) The client is prescribed heparin for treatment. The nurse knows to monitor the client for what adverse effects? A. Migraine attacks B. Hemorrhage C. Respiratory distress D. High blood pressure
B. Hemorrhage
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. Install a bed alarm to remind the client to ask for assistance and to alert staff that the client is getting out of bed.
Which clinical manifestation would be exhibited by a client following a hemorrhagic stroke of the right hemisphere? A. Inability to move the right arm B. Neglect of the left side C. Neglect of the right sidew D. Expressive aphasia
B. Neglect of the left side
The nurse is caring for a client with dysphagia. Which intervention would be contraindicated while caring for this client? A. Assisting the client with meals B. Placing food on the affected side of the mouth C. Testing the gag reflex before offering food or fluids D. Allowing ample time to eat
B. Placing food on the affected side of the mouth
Which health promotion efforts will the nurse encourage to decrease the risk for ischemic stroke? Select all that apply. A. eating fish no more than once a month. B. a low-fat, low-cholesterol diet and increased exercise. C. a high-protein diet and increased weight-bearing exercise. D. a low-cholesterol, low-protein diet and decreased aerobic exercise. E. eat fish 2 or more times a week
B. a low-fat, low-cholesterol diet and increased exercise. E. Eat fish 2 or more times a week
A nurse is caring for a client with a cerebrovascular accident (CVA) The client is prescribed heparin for treatment. The nurse knows to monitor which important lab results? A. INR B. aPTT C. СВС D. PT
B. aPTT
Which clinical manifestations would indicate that a client with dysphagia is having difficulty? A. a lot of burping B. paroxysmal coughing C. c/o hunger D. inability to speak
B. paroxysmal coughing
A white female client is admitted to an acute care facility with a diagnosis of stroke. Her history reveals bronchial asthma, exogenous obesity, and iron-deficiency anemia. Which history finding is a risk factor for stroke? Select all that apply. A. Being white B. Being female C. Being obese D. Having bronchial asthma E. Diabetes F. hypercholesteremia
C. Being obese E. Diabetes F. Hypercholesteremia
A client is brought to the emergency department with symptoms of a cerebrovascular accident (CVA). The nurse would anticipate which diagnostic evaluation to be completed prior to initiation of treatment? A. Prothrombin level B. Chest x-ray C.Brain CT scan or MRI D. Lumbar puncture
C. Brain CT scan or MRI
A patient suffering a stroke is having a difficult time swallowing. What would the nurse document this finding as? A. Ataxia B. Arthralgia C. Dysphagia D. Dysarthria
C. Dysphagia
A client with a neurological disorder has difficulty swallowing. The nurse should take special care with the client's diet because of a potential risk of imbalanced nutrition. Which measure may be taken by the nurse to ensure that the client's diet allows for easy swallowing? A. Instruct the client to lie on the bed when eating B. Offer liquids frequently, in large quantities C. Help the client sit upright when eating and feed slowly D. Allow optimum physical activity before meals to expedite digestion
C. Help the client sit upright when eating and feed slowly
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 which deficit? A. Spatial-perceptual deficits. B. Left visual field deficit. C. Right-sided paralysis. D. Impulsive behavior.
C. Right-sided paralysis.
Which prescription would the nurse anticipate administering within 3 hours of symptoms to a patient diagnosed with an ischemic stroke? A Clopidogrel B. Extended release dipyridamole C. Tissue plasminogen activator (tPA) D. Atorvastatin
C. Tissue plasminogen activator (tPA)
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. "TIA is a warning sign. Let's talk about lowering your risks."
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? A. Neck pain rated 3 of 10 (on a 0 to 10 pain scale) B. Blood pressure 128/86 mm Hg C. Mild neck edema D. Difficulty swallowing
D. Difficulty swallowing
Which is the initial diagnostic test for a stroke? A. Carotid Doppler B. Electrocardiography C. Transcranial Doppler studies D. Noncontrast computed tomography
D. Noncontrast computed tomography
A physician orders aspirin, 325 mg P.O. daily for a client who has experienced a transient ischemic attack (TIA). The nurse should teach the client that the physician has ordered this medication for what reason? A. control headache pain. B. enhance the immune response. C. prevent intracranial bleeding. D. reduce the chance of blood clot formation.
D. reduce the chance of blood clot formation.
