Brunner-Suddarth Med-Surg 13th Ed. Ch. 67

A nurse is instructing the wife of a patient who suffered a stroke about the use of eating devices her husband will be using. During the teaching, the wife starts to cry and states "One minute my husband is laughing, and the next he's crying; I just don't understand what's wrong with him." The nurse's best response is which of the following?

"Following a stroke, emotional lability is common, and it usually improves with time."

Which of the following terms refer to the failure to recognize familiar objects perceived by the senses?

Agnosia

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

Which of the following terms refer to the inability to perform previously learned purposeful motor acts on a voluntary basis?

Apraxia

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

Bleeding

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

A patient diagnosed with a stroke is having difficulty forming words during communication. This would be appropriately documented as which of the following?

Dysarthria

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

Encourage the patient to repeat sounds of the alphabet.

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

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

Frontal

Which of the following is a nonmodifiable risk factor for ischemic stroke?

Gender

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

Heparin sodium

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

History of smoking

Which of the following terms will the nurse use when referring to blindness in the right or left halves of the visual fields of both eyes?

Homonymous hemianopsia

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

A nurse is planning discharge for a client who experienced right-sided weakness caused by a stroke. During his hospitalization, the client has been receiving physical therapy, occupational therapy, and speech therapy daily. The family voices concern about rehabilitation after discharge. How should the nurse intervene?

Inform the case manager of the family's concern and provide information about the client's current clinical status so appropriate resources can be provided after discharge.

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

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

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

Left visual field deficit

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 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

A nurse is teaching about ischemic stroke prevention to a community group and emphasizes that control of hypertension, which is the major risk factor for stroke, is key to prevention. Ways to control hypertension include the Dietary Approaches to Stop Hypertension (DASH) diet. This diet includes which of the following?

Moderate amounts of low-fat dairy products

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

Which of the following is the initial diagnostic in suspected stroke?

Noncontrast computed tomography (CT)

Which of the following would not be a recommended intervention for a patient with dysphagia?

Place food on the affected side of mouth

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 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.

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

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.

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.

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.

Vomiting Seizures Sudden, severe headache

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 knows that, for a patient with an ischemic stroke, tPA is contraindicated if the blood pressure reading is:

190 mm Hg/120 mm Hg

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.

2.5

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?

3 hours

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 is experiencing severe pain related to increased ICP. You are about to administer an analgesic. Which of the following would you expect to be ordered for this client to help alleviate pain?

Codeine

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

Eight days following a subarachnoid hemorrhage, a transcranial Doppler ultrasonography detects cerebral vasospasms in a patient experiencing lethargy. The nurse anticipates which of the following therapeutic interventions?

Nimodipine (Nimotop) po

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)