Chapter 67: Management of Patients With Cerebrovascular Disorders
A client with hypercholesterolemia is receiving Lipitor (atorvastatin) to prevent high cholesterol and stroke. The order is for Lipitor 40 mg PO daily. The medication is supplied in 80 mg tabs. How many tabs will the nurse administer to the client? Enter the correct number ONLY.
0.5 Explanation: 40 mg/80 mg = 0.5 tabs.
Which of the following is the most common side effect of tissue plasminogen activator (tPA)? Bleeding Headache Increased intracranial pressure (ICP) Hypertension
Bleeding Explanation: Bleeding is the most common side effect of tPA. The patient is closely monitored for bleeding (at IV insertion sites, gums, urine/stools, and intracranially by assessing changes in level of consciousness). Headache, increased ICP, and hypertension are not side effects of tPA. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Thrombolytic Therapy, p. 2015.
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 he's crying; I just don't understand what's wrong with him." Which statement is the best response by the nurse? "Emotional lability is common after a stroke, and it usually improves with time." "You sound stressed; maybe using some stress management techniques will help." "You seem upset, and it may be hard for you to focus on the teaching, I'll come back later." "This behavior is common in clients with stroke. Which does your spouse do more often? Laugh or cry?"
"Emotional lability is common after a stroke, and it usually improves with time." Explanation: This is the most therapeutic and informative response. Often, most relatives of clients with stroke handle the physical changes better than the emotional aspects of care. The family should be prepared to expect occasional episodes of emotional lability. The client may laugh or cry easily and may be irritable and demanding or depressed and confused. The nurse can explain to the family that the client's laughter does not necessarily connote happiness, nor does crying reflect sadness, and that emotional lability usually improves with time. The remaining responses are nontherapeutic and do not address the spouse's concerns. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 2023.
Which term refers to the failure to recognize familiar objects perceived by the senses? Agnosia Agraphia Apraxia Perseveration
Agnosia Explanation: Auditory agnosia is failure to recognize significance of sounds. Agraphia refers to disturbances in writing intelligible words. Apraxia refers to an inability to perform previously learned purposeful motor acts on a voluntary basis. Perseveration is the continued and automatic repetition of an activity, word, or phrase that is no longer appropriate. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 2011.
Which term refers to the inability to perform previously learned purposeful motor acts on a voluntary basis? Agnosia Agraphia Perseveration Apraxia
Apraxia Explanation: Verbal apraxia refers to difficulty forming and organizing intelligible words although the musculature is intact. Agnosia is a failure to recognize familiar objects perceived by the senses. Agraphia refers to disturbances in writing intelligible words. Perseveration is the continued and automatic repetition of an activity or word or phrase that is no longer appropriate. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 2011.
Which of the following, if left untreated, can lead to an ischemic stroke? Atrial fibrillation Cerebral aneurysm Arteriovenous malformation (AVM) Ruptured cerebral arteries
Atrial fibrillation Explanation: Atrial fibrillation is the most frequently diagnosed arrhythmia in the United States. If left untreated, it can lead to an ischemic stroke. Cerebral hemorrhage, arteriovenous malformation, and cerebral hemorrhage can lead to a hemorrhagic stroke. Cerebral aneurysm, arteriovenous malformations, and ruptured cerebral arteries can lead to hemorrhagic stroke. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Ischemic Stroke, p. 2010.
The provider diagnoses the patient as having had an ischemic stroke. The etiology of an ischemic stroke would include which of the following? Cardiogenic emboli Cerebral aneurysm Arteriovenous malformation Intracerebral hemorrhage
Cardiogenic emboli Explanation: Aneurysms, hemorrhages, and malformations are all examples of a hemorrhagic stroke. An embolism can block blood flow, leading to ischemia. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Ischemic Stroke, p. 2010.
A nurse practitioner is presenting health information about strokes at a clinic. She mentions that there are five categories of strokes based on their origin. Which of the following is the category that has the highest incidence of strokes (30%)? Cardiogenic embolic Cryptogenic Large artery thrombotic Small artery thrombotic
Cryptogenic Explanation: Cryptogenic strokes, which account for 30% of all strokes, refer to strokes that cannot be attributed to any specific cause. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Ischemic Stroke, p. 2010.
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? Checking stools for occult blood Performing range-of-motion (ROM) exercises on the left side Keeping skin clean and dry Elevating the head of the bed to 30 degrees
Elevating the head of the bed to 30 degrees Explanation: Because the client's gag reflex is absent, elevating the head of the bed to 30 degrees helps minimize the client's risk of aspiration. Checking the stools, performing ROM exercises, and keeping the skin clean and dry are important, but preventing aspiration through positioning is the priority. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Therapy for Patients With Ischemic Stroke Not Receiving Tissue Plasminogen Activator, p. 2017.
Which of the following statements reflects nursing management of the patient with expressive aphasia? Encourage the patient to repeat sounds of the alphabet. Speak clearly and in simple sentences; use gestures or pictures when able. Speak slowly and clearly to assist the patient in forming the sounds. Frequently reorient the patient to time, place, and situation.
Encourage the patient to repeat sounds of the alphabet. Explanation: Nursing management of the patient with expressive aphasia includes encouraging the patient to repeat sounds of the alphabet. Nursing management of the patient with global aphasia includes speaking clearly and in simple sentences and using gestures or pictures when able. Nursing management of the patient with receptive aphasia includes speaking slowing and clearly to assist the patient in forming the sounds. Nursing management of the patient with cognitive deficits, such as memory loss, includes frequently reorienting the patient to time, place, and situation. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Communication Loss, p. 2011.
A client undergoes cerebral angiography for evaluation of a subarachnoid hemorrhage. Which findings indicate spasm or occlusion of a cerebral vessel by a clot? Nausea, vomiting, and profuse sweating Hemiplegia, seizures, and decreased level of consciousness Difficulty breathing or swallowing Tachycardia, tachypnea, and hypotension
Hemiplegia, seizures, and decreased level of consciousness Explanation: Spasm or occlusion of a cerebral vessel by a clot causes signs and symptoms similar to those of a stroke: hemiplegia, seizures, decreased level of consciousness, aphasia, hemiparesis, and increased focal symptoms. Nausea, vomiting, and profuse sweating suggest a delayed reaction to the contrast medium used in cerebral angiography. Difficulty breathing or swallowing may signal a hematoma in the neck. Tachycardia, tachypnea, and hypotension suggest internal hemorrhage. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Vasospasm, p. 2027.
The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regimen, 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: Obesity Dyslipidemia Smoking Hypertension
Hypertension Explanation: Hypertension is the most modifiable risk factor for either ischemic or hemorrhagic stroke. Unfortunately, it remains under-recognized and undertreated in most communities. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Prevention, p. 2013.
A nurse practitioner provides health teaching to a patient who has difficulty managing hypertension. This patient is at an increased risk of which type of stroke? Intracerebral hemorrhage Subarachnoid hemorrhage Hemorrhage due to an aneurysm Arteriovenous malformation
Intracerebral hemorrhage Explanation: About 80% of hemorrhagic strokes are intracerebral, and they are caused primarily by uncontrolled hypertension. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Table 67-5, p. 2018.
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
Ischemic Explanation: Ischemic strokes occur when a thrombus or embolus obstructs an artery carrying blood to the brain; about 80% of strokes are the ischemic variety. The other options are incorrect. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Ischemic Stroke, p. 2009.
Which of the following antiseizure medication has been found to be effective for post-stroke pain? Lamotrigine (Lamictal) Phenytoin (Dilantin) Carbamazepine (Tegretol) Topiramate (Topamax)
Lamotrigine (Lamictal) Explanation: The antiseizure medication lamotrigine (Lamictal) has been found to be effective for post-stroke pain. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Preventing Shoulder Pain, p. 2021.
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 Hemiplegia or hemiparesis Lack of deep tendon reflexes Visual and auditory agnosia
Limited attention span and forgetfulness Explanation: Damage to the frontal lobe may impair learning capacity, memory, or other higher cortical intellectual functions. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and a lack of motivation. Damage to the motor neurons may cause hemiparesis, hemiplegia, and a change in reflexes. Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Cognitive Impairment and Psychological Effects, p. 2011.
The nurse is caring for a client with dysphagia. Which intervention would be contraindicated while caring for this client? Assisting the client with meals Placing food on the affected side of the mouth Testing the gag reflex before offering food or fluids Allowing ample time to eat
Placing food on the affected side of the mouth Explanation: Interventions for dysphagia include placing food on the unaffected side of the mouth, allowing ample time to eat, assisting the client with meals, and testing the client's gag reflex before offering food or fluids. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Table 67-2, p. 2012.
A nurse is planning care for a client who experienced a stroke in the right hemisphere of his brain. What should the nurse do? Anticipate the client will exhibit some degree of expressive or receptive aphasia. Place the wheelchair on the client's left side when transferring him into a wheelchair. Provide close supervision because of the client's impulsiveness and poor judgment. Support the right arm with a sling or pillow to prevent subluxation.
Provide close supervision because of the client's impulsiveness and poor judgment. Explanation: The primary symptoms of a client who experiences a right-sided stroke are left-sided weakness, impulsiveness, and poor judgment. Aphasia is more commonly present when the dominant or left hemisphere is damaged. When a client has one-sided weakness, the nurse should place the wheelchair on the client's unaffected side. Because a right-sided stroke causes left-sided paralysis, the right side of the body should remain unaffected. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Table 67-3, p. 2013.
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? Restrict fluids before surgery. Administer prescribed medications. Administer preoperative sedation. Administer an osmotic diuretic.
Restrict fluids before surgery. Explanation: Before surgery, the nurse should restrict fluids to avoid intraoperative complications, reduce cerebral edema, and prevent postoperative vomiting. The nurse administers prescribed medications such as an anticonvulsant phenytoin, like Dilantin, to reduce the risk of seizures before and after surgery, an osmotic diuretic, and corticosteroids. Preoperative sedation is omitted. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Medical Management, p. 2028.
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: Spatial-perceptual deficits. Left visual field deficit. Right-sided paralysis. Impulsive behavior.
Right-sided paralysis. Explanation: A left hemispheric stroke will cause right-sided weakness or paralysis. Because upper motor neurons decussate, a disturbance on one side of the body can cause damage on the opposite side of the brain. Refer to Box 47-2 in the text. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Table 67-3, p. 2013.
The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient? High-Fowler's Prone Supine Semi-Fowler's
Semi-Fowler's Explanation: The head of the bed is elevated 15 to 30 degrees (semi-Fowler's position) to promote venous drainage and decrease intracranial pressure. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Increased Intracranial Pressure, p. 2027.
Which interventions would be recommended for a client with dysphagia? Select all that apply. Assist the client with meals. Place food on the affected side of the mouth. Test the gag reflex before offering food or fluids. Allow ample time to eat.
Which interventions would be recommended for a client with dysphagia? Select all that apply. Assist the client with meals. Test the gag reflex before offering food or fluids. Allow ample time to eat.
A client is experiencing severe pain related to increased ICP. Which analgesic would be ordered for this client to help alleviate pain? codeine hydrocodone morphine fentanyl
codeine Explanation: Avoid administering opioid analgesics, except codeine. Opioids interfere with accurate assessment of neurologic function because they constrict the pupils and depress LOC.
When communicating with a client who has sensory (receptive) aphasia, the nurse should: allow time for the client to respond. speak loudly and articulate clearly. give the client a writing pad. use short, simple sentences.
use short, simple sentences. Explanation: Although sensory aphasia allows the client to hear words, it impairs the ability to comprehend their meaning. The nurse should use short, simple sentences to promote comprehension. Allowing time for the client to respond might be helpful but is less important than simplifying the communication. Because the client's hearing isn't affected, speaking loudly isn't necessary. A writing pad is helpful for clients with expressive, not receptive, aphasia. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Table 67-2, p. 2012.
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 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." "Clinical manifestations of a stroke depend on how quickly the clot can be dissolved."
"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." Explanation: Clinical manifestations following a stroke are highly variable and depend on the area of the cerebral cortex and the affected hemisphere, the degree of blockage (total, partial), and the presence or absence of adequate collateral circulation. (Collateral circulation is circulation formed by smaller blood vessels branching off from or near larger occluded vessels.) Clinical manifestations of a stroke do not depend on the cardiovascular health of the client or how quickly the clot can be dissolved. Clinical manifestations of a stroke are not "general" but individual. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Introduction, p. 2009.
A client recently experienced a stroke with accompanying left-sided paralysis. His family voices concerns 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? "The client is feeling an emotional loss. He'll eventually start acknowledging you on his left side." "The client is unaware of his left side. You should approach him on the right side." "The client is unaware of his left side. You need to encourage him to interact from this side." "This condition is temporary."
"The client is unaware of his left side. You should approach him on the right side." Explanation: The client is experiencing unilateral neglect and is unaware of his left side. The nurse should advise the family to approach him on his unaffected (right) side. Approaching the client on the affected side would be counterproductive. It's too premature to make the determination whether this condition will be permanent. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Improving Mobility and Preventin Joint Deformities, p. 2019.
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.
4:00 p.m. Explanation: Tissue plasminogen activator (tPA) must be given within 3 hours after symptom onset. Therefore, since symptom onset was 1:00 pm, the window of opportunity ends at 4:00 pm. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Thrombolytic Therapy, p. 2014.
A nurse is caring for a client who has returned to his room after a carotid endarterectomy. Which action should the nurse take first? Ask the client if he has trouble breathing. Take the client's blood pressure. Ask the client if he has a headache. Place antiembolism stockings on the client.
Ask the client if he has trouble breathing. Explanation: The nurse should first assess the client's breathing. A complication of a carotid endarterectomy is an incisional hematoma, which could compress the trachea causing breathing difficulty for the client. Although the other measures are important actions, they aren't the nurse's top priority. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Table 67-5, p. 2018.
Which is a nonmodifiable risk factor for ischemic stroke? Atrial fibrillation Gender Hyperlipidemia Smoking
Gender Explanation: Nonmodifiable risk factors include gender, age, and race. Modifiable risk factors include atrial fibrillation, hyperlipidemia, and smoking. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 2013.
A patient presents to the emergency room with complaints of having an "exploding headache" for the last 2 hours. The patient is immediately seen by a triage nurse who suspects the patient is experiencing a stroke. Which of the following is a possible cause based on the characteristic symptom? Large artery thrombosis Cerebral aneurysm Cardiogenic emboli Small artery thrombosis
Cerebral aneurysm Explanation: A cerebral aneurysm is a type of hemorrhagic stroke that is characterized by an exploding headache. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Intracranial (Cerebral) Aneurysm, p. 2026.
After the patient has received tPA, the nurse knows to check vital signs every 30 minutes for 6 hours. Which of the following readings would require calling the provider? Heart rate of 100 Respiration of 22 Systolic pressure of 130 mm Hg Diastolic pressure of 110 mm Hg
Diastolic pressure of 110 mm Hg Explanation: A diastolic pressure reading of over 105 mm Hg warrants notifying the health care provider. The other choices are within normal range. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Dosage and Administration, p. 2015.
Which is the most common motor dysfunction seen in clients diagnosed with stroke? Ataxia Diplopia Hemiplegia Hemiparesis
Hemiplegia Explanation: The most common motor dysfunction is hemiplegia (paralysis of one side of the body) caused by a lesion on the opposite side of the brain. Ataxia is impaired ability to coordinate movement. Diplopia is double vision. Hemiparesis is weakness of one side of the body. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 2011.
A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? Heparin sodium Dexamethasone Methyldopa Phenytoin
Heparin sodium Explanation: Administering heparin, an anticoagulant, could increase the bleeding associated with hemorrhagic stroke. Therefore, the nurse should question this order to prevent additional hemorrhage in the brain. In a client with hemorrhagic stroke, the healthcare provider may use dexamethasone (Decadron) to decrease cerebral edema and pressure, methyldopa (Aldomet) to reduce blood pressure, and phenytoin (Dilantin) to prevent seizures. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Medical Management, p. 2028.
A diagnostic test has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include thickened liquids. Which of the following is the priority nursing diagnosis for this client? Decreased Fluid Volume Risk Aspiration Risk Impaired Swallowing Malnutrition Risk
Impaired Swallowing Explanation: Impaired Swallowing was evident on the video fluoroscopy. Aspiration, Malnutrition, and Decreased Fluid Volume Risk can occur but are not the primary diagnosis at this point in time. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Table 67-2: Neurologic Deficits of Stroke: Manifestations and Nursing Implications, p. 2012.
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? Decreased level of consciousness (LOC) Elevated blood pressure Increased urine output Decreased heart rate
Increased urine output Explanation: The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output. A decreased LOC and elevated blood pressure may indicate lack of therapeutic effectiveness. A decreased heart rate doesn't indicate that mannitol is effective. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Increased Intracranial Pressure, p. 2027.
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? International normalized ratio greater than 2 Two hour time period of the stroke Taking digoxin Surgery 6 weeks ago
International normalized ratio greater than 2 Explanation: The client is at risk for further bleeding if the international normalized ratio is greater than 2. Thrombolytic therapy must be initiated within 3 hours in clients with ischemic stroke. The client is not eligible for thrombolytic therapy if she has had surgery within 14 days. Digoxin and labetalol do not prohibit thrombolytic therapy. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Chart 67-3, p. 2015.
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? Limited attention span and forgetfulness Visual agnosia Lack of deep tendon reflexes Auditory agnosia
Lack of deep tendon reflexes Explanation: Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia. If damage has occurred to the frontal lobe, learning capacity, memory, or other higher cortical intellectual functions may be impaired. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and lack of motivation. Damage to the lower motor neurons may cause decreased muscle tone, flaccid muscle paralysis, and a decrease in or loss of reflexes. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Motor Loss, p. 2011.
What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke? Left visual field deficit Aphasia Slow, cautious behavior Altered intellectual ability
Left visual field deficit Explanation: A left visual field deficit is a common clinical manifestation of a right hemispheric stroke. Aphasia, slow, cautious behavior, and altered intellectual ability are all clinical manifestations of a left hemispheric stroke. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Table 67-3, p. 2013.
Which of the following is accurate regarding a hemorrhagic stroke? Main presenting symptom is an "exploding headache." Functional recovery usually plateaus at 6 months. One of the main presenting symptoms is numbness or weakness of the face. It is caused by a large-artery thrombosis.
Main presenting symptom is an "exploding headache." Explanation: One of hemorrhagic stroke's main presenting symptom is an "exploding headache." In ischemic stroke, functional recovery usually plateaus at 6 months; it may be caused by a large artery thrombosis and may have a presenting symptoms of numbness or weakness of the face. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Clinical Manifestations, p. 2026.
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? Psychosis, disorientation, delirium, insomnia, and hallucinations Severe dementia and myoclonus Tremor, rigidity, and bradykinesia Choreiform movement and dementia
Psychosis, disorientation, delirium, insomnia, and hallucinations Explanation: Advances in technology have led to the introduction of interventional neuroradiology for the treatment of aneurysms. Endovascular techniques may be used in selected clients to occlude the blood flow from the artery that feeds the aneurysm with coils or other techniques to occlude the aneurysm itself. Postoperative complications are rare but can occur. Potential complications include psychological symptoms such as disorientation, amnesia, and Korsakoff syndrome (disorder characterized by psychosis, disorientation, delirium, insomnia, hallucinations, and personality changes). Creutzfeldt-Jakob disease results in severe dementia and myoclonus. The three cardinal signs of Parkinson disease are tremor, rigidity, and bradykinesia. Huntington disease results in progressive involuntary choreiform (dancelike) movements and dementia. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 2028.
The nurse is completing an assessment on a client with a history of migraines. The nurse would identify which of the following factors as a possible trigger for a migraine headache? Select all that apply. Red wine Nausea Menstruation Exposure to flashing light Change in environmental temperature Prolonged positioning
Red wine Menstruation Exposure to flashing light Research on the cause of migraines is ongoing; however, changes in reproductive hormones (menstruation), exposure to flashing light, and particular food/beverages and alcohol can be a trigger for some clients. Nausea is a symptom of a migraine. Exposure to changes in environmental temperature does not trigger a migraine headache. Prolonged positioning can cause muscle fatigue and strain that trigger tension headaches.
Which is a modifiable risk factor for transient ischemic attacks and ischemic strokes? Thyroid disease Social drinking Advanced age Smoking
Smoking Explanation: Modifiable risk factors for TIAs and ischemic stroke include hypertension, diabetes, cardiac disease, smoking, and excessive alcohol consumption. Advanced age, gender, and race are nonmodifiable risk factors for stroke. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Chart 67-2, p. 2014.
The nurse is participating in a health fair for stroke prevention. Which will the nurse say is a modifiable risk factor for ischemic stroke? Thyroid disease Social drinking Advanced age Smoking
Smoking Explanation: Modifiable risk factors for transient ischemic attack (TIA) and ischemic stroke include hypertension, type 1 diabetes, cardiac disease, smoking, and chronic alcoholism. Advanced age, gender, and race are nonmodifiable risk factors for stroke. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Chart 67-2, p. 2014.
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? Aphasia Spatial-perceptual deficits Slow, cautious behavior Altered intellectual ability
Spatial-perceptual deficits Explanation: Clients with right hemispheric stroke exhibit partial perceptual deficits, left visual field deficit, and paralysis with weakness on the left side of the body. Left hemispheric damage causes aphasia, slow, cautious behavior, and altered intellectual ability. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Table 67-3, p. 2013.
Which of the following diagnostics are beneficial to detect intracranial stenosis? Transcranial Doppler (TCD) Computed tomography (CT) CT with contrast Magnetic resonance imaging (MRI)
Transcranial Doppler (TCD) Explanation: The transcranial Doppler is useful in detecting severe intracranial stenosis, in evaluating the carotid and vertebrobasilar vessels, in assessing patterns and extent of collateral circulation in patients with known arterial stenosis or occlusion, and in detecting microemboli. A CT, CT with contrast, and MRI would not be beneficial for this purpose. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Vasospasm, p. 2027.
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? 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 Vomiting and seizures
Weakness on one side of the body and difficulty with speech Explanation: The main presenting symptoms for an ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body; confusion or change in mental status; and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Foot drop and external hip rotation are things that can occur if a stroke victim is not turned or positioned correctly. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Clinical Manifestations, p. 2011.
A client diagnosed with a stroke is ordered to receive warfarin. Later, the nurse learns that the warfarin is contraindicated and the order is canceled. The nurse knows that the best alternative medication to give is dipyridamole. aspirin. clopidogrel. ticlopidine.
aspirin. Explanation: If warfarin is contraindicated, aspirin is the best option, although other medications may be used if both are contraindicated. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 2013.
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? bruit diplopia atherosclerotic plaque TIA
bruit Explanation: A neurologic examination during an attack reveals neurologic deficits. Auscultation of the artery may reveal a bruit (abnormal sound caused by blood flowing over a rough surface within one or both carotid arteries). The term for the auscultated discovery is "bruit." Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 2011.
A nurse in a rehabilitation facility is coordinating the discharge of a client who is tetraplegic. The client, who is married and has two children in high school, is being discharged to home and will require much assistance. Who would the discharge planner recognize as being the most important member of this client's care team? spouse chaplain home care nurse physical therapist
spouse Explanation: The client's spouse and family would need to be involved in the everyday care of the client; without their support, it is unlikely that the client would be able to manage at home. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Promoting Home, Community-Based, and Transitional Care, p. 2024.
A nurse is reading a journal article about stroke and the underlying causes associated with this condition. The nurse demonstrates understanding of the information when identifying which subtype of stroke as being due to atrial fibrillation? large-artery thrombotic small, penetrating artery thrombotic cardio embolic cryptogenic
cardio embolic Explanation: Ischemic strokes are further divided into five subtypes, according to a mechanism-based classification system: large-artery thrombotic strokes (representing 20% of ischemic strokes); small, penetrating artery thrombotic strokes (25%); cardio embolic strokes (20%); cryptogenic strokes (strokes that cannot be attributed to any specific cause) (30%); and "other" (5%). Large-artery thrombotic strokes are caused by atherosclerotic plaques in the large blood vessels of the brain. Thrombus formation and occlusion can occur at the site of the atherosclerosis and result in ischemia and infarction (tissue death). Small, penetrating artery thrombotic strokes that affect one or more vessels and cause reduced blood flow are the most common type of ischemic stroke, typically caused by longstanding hypertension, hyperlipidemia, or diabetes. Cardio embolic strokes are associated with cardiac dysrhythmias, such as atrial fibrillation, but can also be associated with valvular heart disease or left ventricular thrombus. The last two classifications of ischemic strokes are cryptogenic strokes, which have no identified cause, and strokes from other causes, such as illicit drug use (cocaine), coagulopathies, migraine, or spontaneous dissection of the carotid or vertebral arteries.
The client with a cerebral aneurysm asks the nurse, "What's the big fuss over a headache?" Which is the best response from the nurse regarding to a cerebral aneurysm? "Don't worry. The aneurysm has probably been there since birth." "The headache can be an indication that the aneurysm is growing." "A headache means your aneurysm is leaking blood into the brain." "Your physician wants to evaluate the location and condition of the aneurysm."
"Your physician wants to evaluate the location and condition of the aneurysm." Explanation: Keeping the client calm and quiet is an important aspect of care. Explaining the need for further evaluation is factual. The nurse should avoid saying "don't worry" or telling a client how to feel—this is not a therapeutic response. The aneurysm is growing or leaking are both inappropriate responses from a nurse and can lead to increased concern and anxiety for the client. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Medical Management, p. 2028.
The nurse knows that symptoms associated with a TIA, usually a precursor of a future stroke, usually subside in what period of time? 1 hour 3 to 6 hours 12 hours 24 to 36 hours
1 hour Explanation: A transient ischemic attack (TIA) is a neurologic deficit typically lasting less than 1 hour. A TIA is manifested by a sudden loss of motor, sensory, or visual function. The symptoms result from temporary ischemia (impairment of blood flow) to a specific region of the brain; however, when brain imaging is performed, there is no evidence of ischemia. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Assessment and Diagnostic Findings, p. 2011.
A patient is in the acute phase of an ischemic stroke. How long does the nurse know that this phase may last? Up to 2 weeks Up to 1 week 1 to 3 days Up to 24 hours
1 to 3 days Explanation: The acute phase of an ischemic stroke may last 1 to 3 days, but ongoing monitoring of all body systems is essential as long as the patient requires care. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, The Patient Recovering From an Ischemic Stroke, p. 2018.
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 thrombus formation at the site of the endarterectomy This is a normal occurrence after an endarterectomy and would not be a concern. Bleeding from the endarterectomy site Surgical wound infection
A thrombus formation at the site of the endarterectomy Explanation: Formation of a thrombus at the site of the endarterectomy is suspected if there is a sudden new onset of neurologic deficits, such as weakness on one side of the body. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Nursing Management, p. 2018.
A client has experienced an ischemic stroke that has damaged the temporal (lateral and superior portions) lobe. Which of the following deficits would the nurse expect during assessment of this client? Limited attention span and forgetfulness Hemiplegia or hemiparesis Lack of deep tendon reflexes Auditory agnosia
Auditory agnosia Explanation: Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia. If damage has occurred to the frontal lobe, learning capacity, memory, or other higher cortical intellectual functions may be impaired. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and lack of motivation. Damage to motor neurons may cause hemiparesis, hemiplegia, and a change in reflexes. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Sensory Loss, p. 2011.
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? Neck pain rated 3 of 10 (on a 0 to 10 pain scale) Blood pressure 128/86 mm Hg Mild neck edema Difficulty swallowing
Difficulty swallowing Explanation: The client's inability to swallow without difficulty would cause the nurse the most concern. Difficulty swallowing, hoarseness, or other signs of cranial nerve dysfunction must be assessed. The nurse focuses on assessment of the following cranial nerves: facial (VII), vagus (X), spinal accessory (XI), and hypoglossal (XII). Some edema in the neck after surgery is expected; however, extensive edema and hematoma formation can obstruct the airway. Emergency airway supplies, including those needed for a tracheostomy, must be available. The client's neck pain and mildly elevated blood pressure need to be addressed but would not cause the nurse the most concern. Hypotension is avoided to prevent cerebral ischemia and thrombosis. Uncontrolled hypertension may precipitate cerebral hemorrhage, edema, hemorrhage at the surgical incision, or disruption of the arterial reconstruction. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 2022.
The nurse is caring for a client with aphasia. Which strategy will the nurse use to facilitate communication with the client? Speaking loudly Establishing eye contact Avoiding the use of hand gestures Speaking in complete sentences
Establishing eye contact Explanation: The following strategies should be used by the nurse to encourage communication with a client with aphasia: face the client and establish eye contact, speak in your usual manner and tone, use short phrases, and pause between phrases to allow the client time to understand what is being said; limit conversation to practical and concrete matters; use gestures, pictures, objects, and writing; and as the client uses and handles an object, say what the object is. It helps to match the words with the object or action. Be consistent in using the same words and gestures each time you give instructions or ask a question, and keep extraneous noises and sounds to a minimum. Too much background noise can distract the client or make it difficult to sort out the message being spoken. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Chart 67-5, p. 2023.
How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tPA)? Every 15 minutes Every 30 minutes Every 45 minutes Every hour
Every 15 minutes Explanation: Neurological assessment and vital signs (except temperature) should be taken every 15 minutes initially while the patient is receiving tPA infusion. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Dosage and Administration, p. 2015.
A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take? Use one long sentence to say everything that needs to be said. Keep the television on while she speaks. Talk in a louder than normal voice. Face the client and establish eye contact.
Face the client and establish eye contact. Explanation: When speaking with a client who has aphasia, the nurse should face the client and establish eye contact. The nurse should use short phrases, not one long sentence, and give the client time between phrases to understand what is being said. Keeping extraneous and background noise such as the television to a minimum helps the client concentrate on what is being said. It isn't necessary to speak in a louder or softer voice than normal. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Adjusting to Physical Changes, p. 2022.
Aneurysm rebleeding occurs most frequently during which time frame after the initial hemorrhage? First 2 to 12 hours First 48 hours First week First 2 weeks
First 2 to 12 hours Explanation: Aneurysm rebleeding occurs most frequently during the first 2 to 12 hours after the initial hemorrhage and is considered a major complication. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 2029.
A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to do perform which action? Comprehend spoken words Form understandable words Form understandable words and comprehend spoken words Speak at all
Form understandable words and comprehend spoken words Explanation: Global aphasia is a combination of expressive and receptive aphasia and presents a tremendous challenge to the nurse to communicate effectively with the client. In receptive and expressive aphasia, the client is unable to form words that are understandable. The client who is unable to speak at all is referred to as mute. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Table 67-2, p. 2012.
A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to perform which action? Comprehend spoken words Form words that are understandable Form words that are understandable or comprehend spoken words Speak at all
Form words that are understandable or comprehend spoken words Explanation: Global aphasia is a combination of expressive and receptive aphasia and presents a tremendous challenge to the nurse to effectively communicate with the client. In receptive and expressive aphasia, the client is unable to form words that are understandable. The client who is unable to speak at all is referred to as mute. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Table 67-2, p. 2012.
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 Occipital Parietal Temporal
Frontal Explanation: If damage has occurred to the frontal lobe, learning capacity, memory, or other higher cortical intellectual functions may be impaired. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and a lack of motivation. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Cognitive Impairment and Psychological Effects, p. 2011.
Which term will the nurse use when referring to blindness in the right or left half of the visual field in both eyes? Scotoma Diplopia Nystagmus Homonymous hemianopsia
Homonymous hemianopsia Explanation: Homonymous hemianopsia occurs with occipital lobe tumors. Scotoma refers to a defect in vision in a specific area in one or both eyes. Diplopia refers to double vision or the awareness of two images of the same object occurring in one or both eyes. Nystagmus refers to rhythmic, involuntary movements or oscillations of the eyes. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 2011.
Which terms refers to blindness in the right or left half of the visual field in both eyes? Scotoma Diplopia Nystagmus Homonymous hemianopsia
Homonymous hemianopsia Explanation: Homonymous hemianopsia occurs with occipital lobe tumors. Scotoma refers to a defect in vision in a specific area in one or both eyes. Diplopia refers to double vision or the awareness of two images of the same object occurring in one or both eyes. Nystagmus refers to rhythmic, involuntary movements or oscillations of the eyes. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 2011.
Which is a contraindication for the administration of tissue plasminogen activator (t-PA)? Intracranial hemorrhage Ischemic stroke Age 18 years or older Systolic blood pressure less than or equal to 185 mm Hg
Intracranial hemorrhage Explanation: Intracranial hemorrhage, neoplasm, and aneurysm are contraindications for t-PA. Clinical diagnosis of ischemic stroke, age 18 years or older, and a systolic blood pressure less than or equal to 185 mm Hg are eligibility criteria. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Chart 67-3, p. 2015.
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 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 Maintaining the client in a quiet environment
Keeping the client in one position to decrease bleeding Explanation: The student nurse shouldn't keep the client in one position. She should carefully reposition the client often (at least every hour). The client needs to be positioned so that a patent airway can be maintained. Fluid administration must be closely monitored to prevent complications such as increased intracranial pressure. The client must be maintained in a quiet environment to decrease the risk of rebleeding. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Nursing Interventions, p. 2029.
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? Transient ischemic attack (TIA) Left-sided cerebrovascular accident (CVA) Right-sided cerebrovascular accident (CVA) Completed Stroke
Left-sided cerebrovascular accident (CVA) Explanation: When the infarct is on the left side of the brain, the symptoms are likely to be on the right, and the speech is more likely to be involved. If the MRI reveals an infarct, TIA is no longer the diagnosis. There is not enough information to determine if the stroke is still evolving or is complete. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Table 67-3: Comparison of Left and Right Hemispheric Strokes, p. 2013.
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) Lioresal (Baclofen) Heparin Pregabalin (Lyrica)
Lioresal (Baclofen) Explanation: Spasticity, particularly in the hand, can be a disabling complication after stroke. Botulinum toxin type A injected intramuscularly into wrist and finger muscles has been shown to be effective in reducing this spasticity (although the effect is temporary, typically lasting 2 to 4 months) (Teasell, Foley, Pereira, et al., 2012). Other treatments for spasticity may include stretching, splinting, and oral medications such as baclofen (Lioresal). Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Positioning the Hand and Fingers, p. 2020.
A female client who reports recurring headaches, accompanied by increased irritability, photophobia, and fatigue is asked to track the headache symptoms and occurrence on a calendar log. Which is the best nursing rationale for this action? Cluster headaches can cause severe debilitating pain. Migraines often coincide with menstrual cycle. Tension headaches are easier to treat. Headaches are the most common type of reported pain.
Migraines often coincide with menstrual cycle. Explanation: Changes in reproductive hormones as found during menstrual cycle can be a trigger for migraine headaches and may assist in the management of the symptoms. Cluster headaches can cause severe pain but are not the reason for tracking. Tension headaches can be managed but is not associated with a monthly calendar. Headaches are common but not the reason for tracking. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Pathophysiology, p. 2004.
A client is brought to the emergency department in a confused state, with slurred speech, characteristics of a headache, and right facial droop. The vital signs reveal a blood pressure of 170/88 mm Hg, pulse of 92 beats/minute, and respirations at 24 breaths/minute. On which bodily system does the nurse focus the nursing assessment? Cardiovascular system Respiratory system Endocrine system Neurovascular system
Neurovascular system Explanation: The client is exhibiting signs of an evolving cerebrovascular accident, possibly hemorrhagic in nature, with neurologic complications. Nursing assessment will focus on the neurovascular system assessing level of consciousness, hand grasps, communication deficits, etc. Continual cardiovascular assessment is important but not the main focus of assessment. Respiratory compromise is not noted as a concern. The symptoms exhibited are not from an endocrine dysfunction. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Clinical Manifestations, p. 2026.
A patient having an acute stroke with no other significant medical disorders has a blood glucose level of 420 mg/dL. What significance does the hyperglycemia have for this patient? The patient has new onset diabetes. This is significant for poor neurologic outcomes. The patient has developed diabetes insipidus due to the location of the stroke. The patient has liver failure.
This is significant for poor neurologic outcomes. Explanation: Hyperglycemia has been associated with poor neurologic outcomes in acute stroke and should be treated if the blood glucose is above 140 mg/dL (Summers et al., 2009). Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Managing Potential Complications, p. 2017.
A transcranial Doppler ultrasonography detects cerebral vasospasms in a client experiencing lethargy 8 days following a subarachnoid hemorrhage. The nurse anticipates which therapeutic intervention? Fluid restriction Nitroprusside IV Nimodipine PO Phenytoin IV
Nimodipine PO Explanation: Medication may be effective in the treatment of vasospasm. Based on one theory, that vasospasm is caused by an increased influx of calcium into the cell, medication therapy may be used to block or antagonize this action and prevent or reverse the action of vasospasm if already present. The most frequently used calcium channel blocker is nimodipine. The other interventions and medications are not used to treat vasospasms. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 2027.
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? 12-lead electrocardiogram Carotid ultrasound study Noncontrast computed tomogram Transcranial Doppler flow study
Noncontrast computed tomogram Explanation: The initial diagnostic test for a stroke is usually a noncontrast computed tomography (CT) scan. This should be performed within 25 minutes or less from the time the patient presents to the emergency department (ED) to determine if the event is ischemic or hemorrhagic (the category of stroke determines treatment). Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Assessment and Diagnostic Findings, p. 2011.
A client is suspected of having had a stroke. Which is the initial diagnostic test for a stroke? Carotid Doppler Electrocardiography Transcranial Doppler studies Noncontrast computed tomography
Noncontrast computed tomography Explanation: The initial diagnostic test for a stroke is usually a noncontrast computed tomography (CT) scan. This should be performed within 25 minutes or less from the time the client presents to the ED to determine whether the event is ischemic or hemorrhagic (the category of stroke determines treatment). Further diagnostics include a carotid Doppler, electrocardiogram, and transcranial Doppler. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 2011.
Which of the following is the initial diagnostic in suspected stroke? Noncontrast computed tomography (CT) CT with contrast Magnetic resonance imaging (MRI) Cerebral angiography
Noncontrast computed tomography (CT) Explanation: An initial head CT scan will determine whether or not the patient is experiencing a hemorrhagic stroke. An ischemic infarction will not be readily visible on initial CT scan if it is performed within the first few hours after symptoms onset; however, evidence of bleeding will almost always be visible. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Assessment and Diagnostic Findings, p. 2011.
The nurse is caring for a client recovering from a stroke. Which action will the nurse take to prevent adduction of the client's affected shoulder? Select all that apply. Place a pillow in the axilla area. Position the arm parallel to the torso. Situate the arm in a slightly flexed position. Put a rolled towel in the affected hand. Position the wrist higher than the elbow.
Place a pillow in the axilla area. Position the wrist higher than the elbow. To prevent adduction of the affected shoulder, a pillow is placed in the axilla when there is limited external rotation. Doing so keeps the arm away from the chest. A pillow is placed under the arm, and the arm is placed in a slightly flexed position. Distal joints are to be positioned higher than the more proximal joints, or the wrist positioned higher than the elbow. This helps to prevent edema and the resultant joint fibrosis that will limit range of motion when the client regains control of the arm. A hand roll is not used because it stimulates the grasp reflex. Postioning the arm parallel to the torso could increase edema.
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
Severe headache and early change in level of consciousness Explanation: The main presenting symptoms for ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body, confusion or change in mental status, and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Foot drop and external hip rotation can occur if a stroke victim is not turned or positioned correctly. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Clinical Manifestations, p. 2026.
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? Difficulty breathing Decreased blood pressure Severe unilateral headache Change in vision in one eye
Severe unilateral headache Explanation: Hyperperfusion syndrome occurs when cerebral vessel autoregulation fails. Arteries accustomed to diminished blood flow may be permanently dilated. Increased blood flow after endarterectomy coupled with insufficient vasoconstriction leads to capillary bed damage, edema, and hemorrhage. A unilateral headache that improves by sitting upright or standing is an intervention for this syndrome. Difficulty breathing is an indication of an incisional hematoma. A drop in blood pressure is an indication of postoperative hypotension. A change in vision in one eye could indicate the development of a stroke.
When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke? The day before the patient is discharged After the patient has passed the acute phase of the stroke After the nurse has received the discharge orders The day the patient has the stroke
The day the patient has the stroke Explanation: Although rehabilitation begins on the day the patient has the stroke, the process is intensified during convalescence and requires a coordinated team effort. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Nursing Process, p. 2018.
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 One hour Two hours Six hours
Three hours Explanation: Rapid diagnosis of stroke and initiation of thrombolytic therapy (within 3 hours) in clients with ischemic stroke leads to a decrease in the size of the stroke and an overall improvement in functional outcome after 3 months. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Ischemic Stroke, p. 2009.
A patient diagnosed with an ischemic stroke should be treated within the first 3 hours of symptom onset with which of the following? Clopidogrel Extended release dipyridamole Tissue plasminogen activator (tPA) Atorvastatin
Tissue plasminogen activator (tPA) Explanation: In 1996, the FDA approved the use of tissue plasminogen activator (tPA) for the treatment of acute ischemic stroke within the first 3 hours of symptom onset. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Pathophysiology, p. 2010.
A client is hospitalized when presenting to the emergency department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to his presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what? Left-sided stroke Right-sided stroke Cerebral aneurysm Transient ischemic attack
Transient ischemic attack Explanation: A transient ischemic attack (TIA) is a sudden, brief attack of neurologic impairment caused by a temporary interruption in cerebral blood flow. Symptoms may disappear within 1 hour; some continue for as long as 1 day. When the symptoms terminate, the client resumes his or her presymptomatic state. The symptoms do not describe a left- or right-sided stroke or a cerebral aneurysm. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Assessment and Diagnostic Findings, p. 2011.
The nurse is assessing a 78-year-old female client admitted with a stroke of recent onset, within 2 hours of admission. Vital signs: blood pressure, 150/90 mm Hg; pulse, 112 beats/min; respirations, 20 breaths/min; temperature, 100.4°F (38°C); pulse oximetry, 96% on room air. An audible murmur is heard upon auscultation. The client is awake but somewhat lethargic and cannot respond to questions. The client is exhibiting neurologic deficits and impaired mobility of the left side of the body. The client is being evaluated for tissue plasminogen activator (t-PA) therapy. blood pressure reading computed tomography (CT) confirmation of ischemic stroke international normalized ratio (INR) result of 2.0 National Institutes of Health Stroke Scale (NIHSS) scale result of 17 heart murmur
blood pressure reading computed tomography (CT) confirmation of ischemic stroke National Institutes of Health Stroke Scale (NIHSS) scale result of 17 A client presenting with an ischemic stroke is considered to be a medical emergency because it relates to the administration of tissue plasminogen activator (t-PA) protocol. There are specific time factors related to the onset of symptoms as well as clinical criteria assessments focusing on bleeding/coagulation, history of intracranial trauma, and cardiac (endocarditis) or gastrointestinal bleeding that preclude usage. Tissue plasminogen activator (t-PA) can be administered to clients with a blood pressure range of equal or below 185 mm Hg systolic and equal or below 110 mm Hg diastolic, a confirmed imaging study that identifies an ischemic stroke, and validation of the National Institutes of Health Stroke Scale (NIHSS) scale. An international normalized ratio (INR) reading of 2.0 indicates hypercoagulation; per protocol, the INR should be equal to or less than 1.7. Administration of t-PA to a client with an increased INR can lead to further bleeding. Because the client has a heart murmur in conjunction with an increased temperature, this could suggest the presence of infective endocarditis, which is a contraindication for t-PA therapy.
A client diagnosed with a stroke is having difficulty forming words during communication. This would be appropriately documented as dysphagia. receptive aphasia. dysarthria. diplopia.
dysarthria. Explanation: Dysarthria is difficulty in forming words. Dysphagia is difficulty swallowing. Receptive aphasia is the inability to comprehend the spoken word. Diplopia is double vision. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Table 67-2, p. 2012.
A client's spouse relates how the client reported a severe headache and then was unable to talk or move their right arm and leg. After diagnostics are completed and the client is admitted to the hospital, when would basic rehabilitation begin? immediately in 2 to 3 days after 1 week upon transfer to a rehabilitation unit
immediately Explanation: Beginning basic rehabilitation during the acute phase is an important nursing function. Measures such as position changes and prevention of skin breakdown and contractures are essential aspects of care during the early phase of rehabilitation. The nursing goal is to prevent complications that may interfere with the client's potential to recover function. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 2018.
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 diabetes insipidus hypertension
impaired cerebral circulation Explanation: TIAs involve the same mechanism as in the ischemic cascade, but symptoms are transient (< 24 hours) and there is no evidence of cerebral tissue infarction. The ischemic cascade begins when cerebral blood flow decreases to less than 25 mL/100 g/min and neurons are no longer able to maintain aerobic respiration. Thus, a TIA results directly from impaired blood circulation in the brain. Atherosclerosis, cardiac disease, hypertension, or diabetes can be risk factors for a TIA but do not cause it. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 2010.
