chapter 67 exam 3 testbank questions

which interventions would be recommended for a client with dysphagia? SATA a. assist the client with meals b. place food on the affected side of the mouth c. allow ample time to eat d. test the gag reflex before offering food or fluids

a. assist the client with meals c. allow ample time to eat d. test the gag reflex before offering food or fluids

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. difficulty swallowing b. blood pressure 128/86 c. neck pain rated 3 out of 10 (on scale of 1-10) d. mild neck edema

a. difficulty swallowing

the statements presented match nursing interventions with nursing diagnoses. which statements are true for a client with a stroke? SATA a. disturbed sensory perception: stand on the clients unaffected side b. impaired physical mobility: provide wide grip utensils during meals c. self care deficit: instruct the client on use of a walker d. impaired swallowing: provide a pureed diet e. impaired verbal communication: repeat words and instructions

a. disturbed sensory perception: stand on the clients unaffected side d. impaired swallowing: provide a pureed diet e. impaired verbal communication: repeat words and instructions

which is a nonmodifiable risk factor for ischemic stroke? a. atrial fibrillation b. gender c. smoking d. hyperlipidemia

b. gender

which is the initial diagnostic test for a stroke? a. transcranial doppler studies b. non-contrast computed tomography c. carotid doppler d. electrocardiography

b. non-contrast computed tomography

which interventions would be contraindicated for a client with dysphagia? a. assist the client with meals b. place food on the affected side of the mouth c. allow ample time to eat d. test the gag reflex before offering food or fluids

b. place food on the affected side of the mouth

which set of symptoms characterize Korsakoff syndrome? a. choreiform movement and dementia b. psychosis, disorientation, delirium, insomnia, and hallucinations c. tremor, rigidity, and bradykinesia d. severe dementia and myoclonus

b. psychosis, disorientation, delirium, insomnia, and hallucinations

which is a modifiable risk factor for transient ischemic attacks and ischemic strokes? a. advanced age b. smoking c. thyroid disease d. social drinking

b. smoking

which statements reflect the nursing management of a client with receptive aphasia? a. encourage the client to repeat sounds of the alphabet b. speak slowly and clearly to assist the client in forming the sounds c. speak clearly to the client in simple sentences, and use gestures or pictures when stable d. frequently reorient the client to time, place, and situation

b. speak slowly and clearly to assist the client in forming the sounds

a nurse is instructing the spouse of a client who suffered a stroke about the use of eating devices the client will be using. during the teaching, the spouse starts to cry and states, "one minute he is laughing, and the next hes crying. i just dont understand whats wrong with him" which statement is the best response by the nurse? a. you sound stressed, maybe using some stress management techniques will help b. this behavior is common in clients with stroke. which does your spouse do more often, laugh or cry? c. you seem upset, and it may be hard for you to focus on the teaching, ill come back later d. emotional lability is common after a stroke, and it usually improves with time

d. emotional lability is common after a stroke, and it usually improves with time

which statement reflects nursing management of the client with expressive aphasia? a. speak slowly and clearly to assist the client in forming the sounds b. speak clearly to the client in simple sentences, and use gestures or pictures when stable c. frequently reorient the client to time, place, and situation d. encourage the client to repeat sounds of the alphabet

d. encourage the client to repeat sounds of the alphabet

which clinical manifestation would be exhibited by a client following a hemorrhagic stroke of the right hemisphere? a. expressive aphasia b. neglect of the side opposite to the hemisphere affected c. inability to move the right arm d. neglect of the left side

d. neglect of the left side

the nurse is caring for a client diagnosed with a subarachnoid hemorrhage resulting from a leaking aneurysm. the client is awaiting surgery. which nursing interventions would be appropriate for the nurse to implement? SATA a. elevate head of bed to 30 degrees b. permit friends to visit often c. provide a dimly lit environment d. ambulate the client every hour e. administer docusate per order

a. elevate head of bed to 30 degrees c. provide a dimly lit environment e. administer docusate per order

the nurse is caring for a client with aphasia. which strategy will the nurse use to facilitate communication with the client? a. establishing eye contact b. avoiding the use of hand gestures c. speaking loudly d. speaking in complete sentences

a. establishing eye contact

aneurysm rebleeding occurs most frequently during which time frame after the initial hemorrhage? a. first 2-12 hours b. first week c. first 2 weeks d. first 48 hours

a. first 2-12 hours

a client has been diagnosed as having global aphasia. the nurse recognizes that the client will be unable to perform which action? a. form words that are understandable or comprehend spoken words b. form words that are understandable c. comprehend spoken words d. speak at all

a. form words that are understandable or comprehend spoken words

which is the most common motor dysfunction seen in clients diagnosed with stroke? a. hemiplegia b. diplopia c. ataxia d. hemiparesis

a. hemiplegia

which is indicative of a right hemisphere stroke? a. spatial-perceptual deficits b. altered intellectual ability c. slow, cautious behavior d. aphasia

a. spatial-perceptual deficits

which term refers to the failure to recognize familiar objects perceived by the senses? a. apraxia b. agnosia c. perseveration d. agraphia

b. agnosia

a client diagnosed with a stroke is having difficulty forming words during communication. this would be appropriately documented as a. repetitive aphasia b. dysarthria c. diplopia d. dysphagia

b. dysarthria

thrombolytic therapy should be initiated within what time frame of an ischemic stroke to achieve the best functional outcome? a. 12 hours b. 6 hours c. 3 hours d. 9 hours

c. 3 hours

if warfarin is contraindicated as a treatment for stroke, which medication is the best option? a. Clopidogrel b. Ticlodipine c. Aspirin d. Dipyridamole

c. Aspirin

a 45 year old 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. trauma b. intracerebral aneurysm rupture c. cocaine use d. arteriovenous malformation

c. cocaine use

a client with a neurological disorder has difficulty swallowing. the nurse should take special care with the clients 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. offer liquids frequently, in large quantities b. instruct the client to lie on the bed when eating 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

which term refers to blindness in the right or left half of the visual field in both eyes? a. scotoma b. Nystagmus c. homonymous hemianopsia d. diplopia

c. homonymous hemianopsia

which is a contraindication for the administration of tissue plasminogen activator (T-PA)? SATA a. ischemic stroke b. 18 years of age or older c. intracranial hemorrhage d. systolic blood pressure less than or equal to 185mmHg e. major abdominal surgery within 10 days

c. intracranial hemorrhage e. major abdominal surgery within 10 days

health promotion efforts to decrease the risk for ischemic stroke involve encouraging a healthy lifestyle including a. a high protein diet and increased weight bearing exercise b. eating fish no more than once a month c. low fat, low cholesterol diet and increased exercise d. low cholesterol, low protein diet and decreased aerobic exercise

c. low fat, low cholesterol diet and increased exercise

the nurse is caring for a client diagnosed with a hemorrhagic stroke. the nurse recognizes that which intervention is most important? a. administering a stool softener b. elevating the head of bed to 30 degrees c. maintaining a patent airway d. monitoring for seizure activity

c. maintaining a patent airway

a transcranial doppler ultrasonography detects cerebral vasospasms in a client experiencing lethargy 8 days following a subarachnoid hemorrhage. the nurse anticipates which therapeutic intervention? a. Phenytoin IV b. fluid restriction c. Nitroprusside IV d. Nimodipine PO

d. Nimodipine PO

which term refers to the inability to perform previously learned purposeful motor acts on a voluntary basis? a. preserveration b. agraphia c. agnosia d. apraxia

d. apraxia

which insult or abnormality can cause an ischemic stroke? a. arteriovenous malformation b. trauma c. intracerebral aneurysm rupture d. cocaine use

d. cocaine use

a client with CVA is prescribed medication to treat the disorder. the client wants to know what other measures may help reduce CVA. which is an accurate suggestion for the client? a. increase body weight moderately b. increase intake of proteins and carbohydrates c. increase hydration and the intake of fluids d. reduce hypertension and high blood cholesterol

d. reduce hypertension and high blood cholesterol