CVA Moody
A client is admitted to the hospital with weakness in the right extremities and speech that is slightly slurred. A diagnosis of brain attack (cerebrovascular accident, CVA) is suspected. During the first 24 hours after symptom onset, the priority nursing intervention is to:
Evaluate motor status
A client is diagnosed with a brain attack (cerebrovascular accident, CVA). The baseline vital signs are a pulse rate of 78 and a blood pressure (BP) of 120/80. The nurse continues to monitor the vital signs and recognizes that which changes in vital signs indicate increased intracranial pressure (ICP)?
Pulse 50 and BP 140/60 Increasing intracranial pressure is evidenced by widening of pulse pressure and a decreased pulse rate.
A client is admitted with a brain attack (cerebrovascular accident, CVA) with left-sided paralysis. The client leans to the left when placed in a sitting position and fails to respond to stimuli in the left visual field. The client's plan of care should include:
Teaching the client to use head movements to scan the left field of vision
Which health problem does the nurse identify from an older client's history that increases the client's risk factors for a cerebrovascular accident (CVA, also known as "brain attack")?
Transient ischemic attacks (TIAs)
A client experiences expressive aphasia as a result of a brain attack (cerebrovascular accident, CVA). The client's spouse asks whether the client's speech will ever return. What is the best response by the nurse?
"It is hard to say how much improvement will occur."
A 50-year-old male client has difficulty communicating because of expressive aphasia after a cerebrovascular accident (CVA, also known as a "brain attack"). When the nurse asks the client how he is feeling, his wife answers for him. How should the nurse address this behavior?
Acknowledge the wife but look at the client for a response
A client is admitted to a rehabilitation unit after a brain attack (cerebrovascular accident, CVA) with residual hemiparesis. To help achieve the goal of safe walking with a cane, the nurse should teach the client to:
Advance the cane and the affected extremity simultaneously
A client who had a brain attack (cerebrovascular accident, CVA) two weeks ago is having problems communicating. The nurse shows the client a picture of a baseball and asks the client to identify it and its characteristics. The client describes its color, size, and purpose but cannot identify it as a ball. The nurse documents this response as:
Anomia Clients with anomia cannot remember names of objects.
Three days after admission to the hospital for a brain attack (cerebrovascular accident, CVA), a client has a nasogastric tube inserted and is receiving continuous tube feedings. What should the nurse do to best evaluate whether the feeding is being absorbed?
Aspirate for a residual volume.
The family members of a client with the diagnosis of cerebrovascular accident (CVA, also known as "brain attack") express concern that the client often becomes uncontrollably tearful during their visits. What should the nurse include in a response?
Emotional lability is associated with brain trauma
The spouse of a client who had a cerebrovascular accident (CVA, also known as "brain attack:) insists on doing everything for the client during visits. After these visits, the client seems to be depressed. The nurse understands that these visits probably have what effect on the client?
Feeling the loss of independence
Family members of a client who had a brain attack (cerebrovascular accident, CVA) ask why the client cries easily and without provocation. The nurse explains that the client:
Has little control over this behavior
A client who had a cerebrovascular accident (CVA, also known as "brain attack") is starting to eat lunch. What client behavior indicates to the nurse that the client may be experiencing left hemianopsia?
Ignores the food on the left side of the tray when eatin
A client manifests right-sided hemianopsia as a result of a brain attack (cerebrovascular accident, CVA). The nurse develops a plan of care and includes:
Instruct the client to scan surroundings
A client experiences a cerebral vascular accident (CVA) and is admitted to the hospital in a coma. What is the priority nursing care for this client?
Maintain an open airway
The nurse is caring for a client two days after the client had a brain attack (cerebrovascular accident, CVA). To prevent the development of plantar flexion, the nurse should:
Maintain the feet at right angles to the legs
A client with a history of hypertension is admitted to the hospital immediately after a brain attack (cerebrovascular accident, CVA). The client is unconscious and the vital signs are temperature 98°F, pulse 78, respiration 16, and blood pressure 120/80. Which nursing concern is a priority for this client?
Respiratory distress
While hospitalized, a client has a hypertensive crisis and a brain attack (cerebrovascular accident, CVA). Initially, the nurse should place the client in what position?
Side-lying
An older client experiences a cerebral vascular accident (CVA) and has right-sided hemiplegia and expressive aphasia. The client's children ask the nurse which functions will be impaired. The nurse explains that the abilities that will be affected include:
Stating wishes verbally
The nurse is providing post-procedure care for a client that had a central venous access device (CVAD) inserted. Before the CVAD is used, what procedure is performed to verify placement?
Chest x-ray
