NUR 222 - Ch 47 - PrepU
According to stroke performance measures, nonambulatory patients diagnosed with either hemorrhagic or ischemia stroke should start receiving deep venous thrombosis (DVT) prophylaxis by the end of which day?
2 (p. 1248)
A 154-pound woman has been prescribed tPA (0.9 mg/kg) for an ischemic stroke. The nurse knows to give how many mg initially?
6.3 mg (????? feedback sent) (p. 1256)
Which term refers to the failure to recognize familiar objects perceived by the senses?
Agnosia (p. 1252)
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. (p. 1264)
While the nurse is making initial rounds after coming on shift, you find a client thrashing about in bed complaining of a severe headache. The client tells the nurse the pain is behind the right eye, which is red and tearing. What type of headache would the nurse suspect this client of having?
Cluster
A patient suffering a stroke is having a difficult time swallowing. What would the nurse document this finding as?
Dysphagia (p. 1264)
The nurse is caring for a client who has had a cerebrovascular accident. The client has a nursing diagnosis of altered nutritional status related to difficulty swallowing. What intervention would it be important for the nurse to institute?
Encourage the client to eat semisolid foods and cold foods. (p. 1264)
From which direction should a nurse approach a client who is blind in the right eye?
From the left side of the client (p. 1263)
Which disturbance results in loss of half of the visual field?
Homonymous hemianopsia (pp. 1263-1264)
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 (p. 1250)
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 (pp. 1256-1257)
A client has experienced an ischemic stroke that has damaged the lower motor neurons of the brain. Which of the following deficits would the nurse expect during assessment?
Lack of deep tendon reflexes
A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings?
Left-sided cerebrovascular accident (CVA)
Which is the initial diagnostic test for a stroke?
Noncontrast computed tomography (p. 1256)
Which of the following is the initial diagnostic in suspected stroke?
Noncontrast computed tomography {CT} (p. 1247)
A client with a cerebrovascular accident (CVA) is having difficulty with eating food on the plate. Which is the best priority nursing action to be taken?
Perform a vision field assessment.
What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke?
You Selected: Aphasia Correct response: Left visual field deficit (p. 1251)
A client admitted to the emergency department is being evaluated for the possibility of a stroke. Which assessment finding would lead the nurse to suspect that the client is experiencing a hemorrhagic stroke?
severe exploding headache
Which of the following is the most common side effect of tissue plasminogen activator {tPA}?
Bleeding (p. 1247)
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?
Cerebral aneurysm (p. 1247)
A patient has been diagnosed as having global aphasia. The nurse recognizes that the patient will be unable to complete which of the following?
Form words that are understandable or comprehend the spoken word (p. 1264)
A client tells the nurse that they have transient ischemic attacks. The client reports having undergone a carotid artery surgery. In such a case, what important assessments should be performed by the nurse?
Frequent neurologic checks (p. 1261)
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 (p. 1252)
Which is a nonmodifiable risk factor for ischemic stroke?
Gender (p. 1251)
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?
Transient ischemic attack (p. 1250)
Which of the following is the chief cause of intracerebral hemorrhage (ICH)?
Uncontrolled hypertension (p. 1249)
A client with a history of atrial fibrillation has experienced a TIA. In an effort to reduce the risk of cerebrovascular accident (CVA), the nurse anticipates the priority medical treatment to include which of the following?
Anticoagulant therapy
A patient is admitted via ambulance to the emergency room of a stroke center at 1:30 p.m. with symptoms that the patient said began at 1:00 p.m. Within 1 hour, an ischemic stroke had been confirmed and the doctor ordered tPA. The nurse knows to give this drug no later than what time?
4:00 p.m. (p. 1248, 1253)
Evaluating the level of consciousness using the Glasgow Coma Scale is an essential nursing assessment for a patient who has had an intracerebral hemorrhage. Which of the following scores would indicate the need for immediate intubation?
8 (p. 1259)
A nurse is assisting with a community screening for people at high risk for stroke. To which of the following clients would the nurse pay most attention?
A 60-year-old African-American man (p. 1251)
During assessment of cognitive impairment, post-stroke, the nurse documents that the patient was experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe?
Frontal (p. 1252)
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.
Which is a modifiable risk factor for transient ischemic attacks and ischemic strokes?
Smoking (p. 1250)
Which is indicative of a right hemisphere stroke?
Spatial-perceptual deficits (p. 1252)
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
The geriatric advanced practice nurse (APN) is doing client teaching with a client who has had a cerebrovascular accident (CVA) and the client's family. One concern the APN addresses is a potential for falls related to the CVA and resulting muscle weakness. What would be most important for the APN to include in teaching related to this concern?
Remove throw rugs and electrical cords from home environment.
The nurse practitioner is able to correlate a patient's neurologic deficits with the location in the brain affected by ischemia or hemorrhage. For a patient with a left hemispheric stroke, the nurse would expect to see:
Right-sided paralysis. (p. 1251)
The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient?
Semi-Fowler's (p. 1262)
A patient is exhibiting classic signs of a hemorrhagic stroke. What complaint from the patient would be an indicator of this type of stroke?
Severe headache (p. 1251)
While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are:
Severe headache and early change in level of consciousness