nurs 273 stroke

The nurse is performing an assessment on a client with a diagnosis of thrombotic stroke (brain attack). Which assessment question would elicit data specific to this type of stroke? "Have you had any headaches in the past few days?" "Have you recently been having difficulty with seeing at nighttime?" "Have you had any sudden episodes of passing out in the past few days?" "Have you had any numbness or tingling or paralysis-type feelings in any of your extremities recently?"

"Have you had any numbness or tingling or paralysis-type feelings in any of your extremities recently?" Cerebral thrombosis (thrombotic stroke) does not occur suddenly. In the few days or hours preceding the thrombotic stroke, the client may experience a transient loss of speech, hemiparesis, or paresthesias on 1 side of the body. Signs and symptoms of this type of stroke vary but may also include dizziness, cognitive changes, or seizures. Headache is rare, but some clients with stroke experience signs and symptoms similar to those of cerebral embolism or intracranial hemorrhage. The client does not complain of difficulty with night vision as part of this clinical problem. In addition, most clients do not have repeated episodes of loss of consciousness.

The nurse is caring for a client who is in the chronic phase of stroke (brain attack) and has a right-sided hemiparesis. The nurse identifies that the client is unable to feed self. Which is the appropriate nursing intervention? Assist the client to eat with the left hand to build strength. Provide a pureed diet that is easy for the client to swallow. Inform the client that a feeding tube will be placed if progress is not made. Provide a variety of foods on the meal tray to stimulate the client's appetite.

Assist the client to eat with the left hand to build strength. Right-sided hemiparesis is weakness of the right arm and leg. The nurse should teach the client to use both sides of the body to increase strength and build endurance. Providing a pureed diet is incorrect. The question does not mention swallowing difficulty, so there is no need to puree the food. Informing the client that a feeding tube may need to be placed is incorrect. That information would come from the primary health care provider. Providing a variety of foods is also incorrect because the problem is not the food selection but the client's ability to eat the food independently.

The nurse is creating a plan of care for a client with a stroke (brain attack) who has global aphasia. The nurse should incorporate communication strategies into the plan of care because of which expected characteristic of the client's speech? Intact Rambling Characterized by literal paraphasia Associated with poor comprehension

Associated with poor comprehension Global aphasia is a condition in which the affected person has few language skills as a result of extensive damage to the left hemisphere. The speech is nonfluent and is associated with poor comprehension and limited ability to name objects or repeat words. The client with conduction aphasia has difficulty repeating words spoken by another, and speech is characterized by literal paraphasia with intact comprehension. The client with Wernicke's aphasia may exhibit a rambling type of speech.

At 8:00 a.m., a client who has had a stroke (brain attack) was awake and alert with vital signs of temperature 98º F (37.2º C) orally, pulse 80 beats/min, respirations 18 breaths/min, and blood pressure 138/80 mm Hg. At noon, the client is confused and only responsive to tactile stimuli, and vital signs are temperature 99º F (36.7º C) orally, pulse 62 beats/min, respirations 20 breaths/min, and blood pressure 166/72 mm Hg. The nurse should take which action? Reorient the client. Retake the vital signs. Call the primary health care provider (PHCP). Administer an antihypertensive PRN (as needed).

Call the primary health care provider (PHCP). The important nursing action is to call the PHCP. The deterioration in neurological status, decreasing pulse, and increasing blood pressure with a widening pulse pressure all indicate that the client is experiencing increased intracranial pressure, which requires immediate treatment to prevent further complications and possible death. The nurse should retake the vital signs and reorient the client to surroundings. If the client's blood pressure falls within parameters for PRN antihypertensive medication, the medication also should be administered. However, options 1, 2, and 4 are secondary nursing actions.

A client who suffered a stroke is prepared for discharge from the hospital. The primary health care provider has prescribed range-of-motion (ROM) exercises for the client's right side. What action should the nurse include in the client's plan of care? Implement ROM exercises to the point of pain for the client. Consider the use of active, passive, or active-assisted exercises in the home. Encourage the client to be dependent on the home care nurse to complete the exercise program. Develop a schedule of ROM exercises every 2 hours while awake even if the client is fatigued.

Consider the use of active, passive, or active-assisted exercises in the home. The home care nurse must consider all forms of ROM for the client. Even a client with hemiplegia can participate in some components of rehabilitative care. In addition, the goal in home care nursing is for the client to assume as much self-care and independence as possible. The nurse needs to teach home care measures so that the client becomes self-reliant. The options of performing ROM exercises to the point of pain and performing ROM exercises every 2 hours while the client is awake even if fatigued are incorrect from a physiological standpoint.

The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully? Gets angry with family if they interrupt a task Experiences bouts of depression and irritability Has difficulty with using modified feeding utensils Consistently uses adaptive equipment in dressing self

Consistently uses adaptive equipment in dressing self Clients are evaluated as coping successfully with lifestyle changes after a stroke if they make appropriate lifestyle alterations, use the assistance of others, and have appropriate social interactions. Options 1 and 2 are not adaptive behaviors; option 3 indicates a not yet successful attempt to adapt.

The nurse assesses a client who is diagnosed with a stroke (brain attack). On assessment, the client is unable to understand the nurse's commands. Which condition should the nurse document? Occipital lobe impairment Damage to the auditory association areas Frontal lobe and optic nerve tracts damage Difficulty with concept formation and abstraction areas

Damage to the auditory association areas Auditory association and storage areas are located in the temporal lobe and relate to understanding spoken language. The occipital lobe contains areas related to vision. The frontal lobe controls voluntary muscle activity, including speech, and an impairment can result in expressive aphasia. The parietal lobe contains association areas for concept formation, abstraction, spatial orientation, body and object size and shape, and tactile sensation.

Which assessment finding should the nurse expect to note in the client hospitalized with a diagnosis of stroke who has difficulty chewing food? Dysfunction of vagus nerve (cranial nerve X) Dysfunction of trigeminal nerve (cranial nerve V) Dysfunction of hypoglossal nerve (cranial nerve XII) Dysfunction of spinal accessory nerve (cranial nerve XI)

Dysfunction of trigeminal nerve (cranial nerve V) The motor branch of cranial nerve V is responsible for the ability to chew food. The vagus nerve is active in parasympathetic functions of the autonomic nervous system. The hypoglossal nerve aids in swallowing. The spinal accessory nerve is responsible for shoulder movement, among other things.

A client is newly admitted to the hospital with a diagnosis of stroke (brain attack) manifested by complete hemiplegia. Which item in the medical history of the client should the nurse be most concerned about? Glaucoma Emphysema Hypertension Diabetes mellitus

Emphysema The nurse should be most concerned about emphysema. The respiratory system is the priority in the acute phase of a stroke. The client with a stroke is vulnerable to respiratory complications such as atelectasis and pneumonia. Because the client has complete hemiplegia (is unable to move) and has emphysema, these risks are very significant. Although the other conditions of glaucoma, hypertension, and diabetes mellitus are important, they are not as significant as emphysema.

The nurse is assessing the function of cranial nerve XII in a client who sustained a stroke. To assess function of this nerve, which action should the nurse ask the client to perform? Extend the arms. Extend the tongue. Turn the head toward the nurse's arm. Focus the eyes on the object held by the nurse.

Extend the tongue. mpairment of cranial nerve XII can occur with a stroke. To assess the function of cranial nerve XII (the hypoglossal nerve), the nurse would assess the client's ability to extend the tongue. The maneuvers noted in the remaining options do not test the function of cranial nerve XII.

The nurse is caring for a client who has just been admitted to the hospital with a diagnosis of a hemorrhagic stroke. The nurse should place the client in which position? Prone Supine Semi-Fowler's with the hip and the neck flexed Head of the bed elevated 30 degrees with the head in midline position

Head of the bed elevated 30 degrees with the head in midline position The primary health care provider's prescriptions are always followed with regard to positioning the client after stroke. Clients with hemorrhagic stroke usually have the head of the bed elevated to 30 degrees to reduce intracranial pressure that can occur from the hemorrhage. The head should be in a midline, neutral position to facilitate venous drainage from the brain. Extreme hip and neck flexion should be avoided to prevent an increase in intrathoracic pressure and to promote venous drainage from the brain. For clients with ischemic stroke, the head of the bed usually is kept flat to ensure adequate blood flow and thus oxygenation to the brain. Prone, supine, and hip and neck flexion are incorrect positions for clients with hemorrhagic stroke.

The nurse is instructing a client who had a stroke and has weakness on 1 side how to ambulate with the use of a cane. Which instruction should the nurse provide to the client? Hold the cane on the affected (weak) side. Hold the cane on the unaffected (strong) side. Move the cane forward first along with the unaffected (strong) leg. Move the cane and the unaffected (strong) leg down first when going down stairs.

Hold the cane on the unaffected (strong) side. The cane is kept on the strong side of the body. It would be hard to hold the cane on the weak side. The cane is assisting the weakened leg, so the weakened leg moves with the cane, or right after it, in ambulating or in going down stairs.

The nurse is performing a neurological assessment on a client who had a stroke (brain attack). The nurse checks for proprioception using which assessment technique? Tapping the Achilles tendon using the reflex hammer Gently pricking the client's skin on the dorsum of the foot in 2 places Firmly stroking the lateral sole of the foot and under the toes with a blunt instrument Holding the sides of the client's great toe and, while moving it, asking what position it is in

Holding the sides of the client's great toe and, while moving it, asking what position it is in A method of testing for proprioception is to hold the sides of the client's great toe and, while moving it, asking the client what position it is in. Tapping the Achilles tendon with a reflex hammer describes gastrocnemius muscle contraction. Pricking the skin on the dorsum of the foot in 2 different places describes 2-point discrimination. The plantar reflex is tested when the sole of the foot is stroked with a blunt instrument.

The nurse is creating a plan of care for a client with a diagnosis of stroke (brain attack) with anosognosia. To meet the needs of the client with this deficit, the nurse should include activities that will achieve which outcome? Encourage communication. Provide a consistent daily routine. Promote adequate bowel elimination. Increase the client's awareness of the affected side.

Increase the client's awareness of the affected side. In anosognosia, the client exhibits neglect of the affected side of the body. The nurse will plan care activities that remind the client to perform actions that require looking at the affected arm or leg, as well as activities that will increase the client's awareness of the affected side. The remaining options are not associated with this deficit.

The nurse is creating a plan of care for a client with a stroke (brain attack) who has right homonymous hemianopsia. Which should the nurse include in the plan of care for the client? Place an eye patch on the left eye. Place personal articles on the client's right side. Approach the client from the right field of vision. Instruct the client to turn the head to scan the right visual field.

Instruct the client to turn the head to scan the right visual field. Homonymous hemianopsia is a loss of half of the visual field. The nurse instructs the client to scan the environment and stands within the client's intact field of vision. The nurse should not patch the eye because the client does not have double vision. The client should have objects placed in the intact fields of vision, and the nurse should approach the client from the intact side.

The nurse is caring for a client with a diagnosis of right (nondominant) hemispheric stroke. The nurse notes that the client is alert and oriented to time and place. On the basis of these assessment findings, the nurse should make which interpretation? Had a very mild stroke Most likely suffered a transient ischemic attack May have difficulty with language abilities only Is likely to have perceptual and spatial disabilities

Is likely to have perceptual and spatial disabilities The client with a right (nondominant) hemispheric stroke may be alert and oriented to time and place. These signs of apparent wellness often suggest that the client is less disabled than is the case. However, impulsivity and confusion in carrying out activities may be very real problems for these clients as a result of perceptual and spatial disabilities. The right hemisphere is considered specialized in sensory-perceptual and visual-spatial processing and awareness of body space. The left hemisphere is dominant for language abilities.

The home care nurse is visiting a male client who is recovering at home after suffering a brain attack (stroke) 2 weeks ago. The client's wife states that the client has difficulty feeding himself and difficulty with swallowing food and fluids. Which would be the initial nursing action? Observe the client feeding himself. Observe the wife feeding the client. Arrange for a home health aide to assist at mealtimes. Instruct the wife in the use of a feeding syringe to feed the client.

Observe the client feeding himself. It is not uncommon for a client to have difficulty swallowing after experiencing a stroke. Often the client has hemiplegia. The arm on the affected side may be paralyzed, and the client may have to learn to use the opposite arm for self-feeding. Using the nondominant arm may require rehabilitation and retraining. Also, a client may have partial paralysis of the mouth, tongue, or esophagus. To best assist the client, the nurse should first assess the situation by watching the self-feeding process. Perhaps the problem lies in the feeding technique, the type of feeding tool used, the types of foods being served, or a combination. Having someone else feed the client may be necessary if self-feeding is not possible. This approach, however, does not promote independence for the client. A feeding syringe is not recommended for feeding most clients.

A client has sustained damage to Wernicke's area from a stroke (brain attack). On assessment of the client, which sign or symptom would be noted? Difficulty speaking Problem with understanding language Difficulty controlling voluntary motor activity Problem with articulating events from the remote past

Problem with understanding language Wernicke's area consists of a small group of cells in the temporal lobe whose function is the understanding of language. Damage to Broca's area is responsible for aphasia. The motor cortex in the precentral gyrus controls voluntary motor activity. The hippocampus is responsible for the storage of memory.

A client who has experienced a stroke has partial hemiplegia of the left leg. The nurse interprets that the client could benefit from the support and stability provided by which item? Quad cane Wheelchair Lofstrand crutch Aluminum crutch

Quad cane quad cane may be used by the client requiring greater support and stability than is provided by a straight leg cane. The quad cane provides a four-point base of support and is indicated for use by clients with partial or complete hemiplegia. Neither crutches nor a wheelchair is indicated for use with a client such as the one described in the question.

At the end of the work shift, the nurse is reviewing the respiratory status of a client admitted with a stroke (brain attack) earlier in the day. The nurse determines that the client's airway is patent if which data are identified? Respiratory rate 24 breaths/min, oxygen saturation 94%, breath sounds clear Respiratory rate 18 breaths/min, oxygen saturation 98%, breath sounds clear Respiratory rate 16 breaths/min, oxygen saturation 85%, wheezes bilaterally Respiratory rate 20 breaths/min, oxygen saturation 92%, diminished breath sounds in lung bases

Respiratory rate 18 breaths/min, oxygen saturation 98%, breath sounds clear The client's airway is most protected if all of the respiratory parameters measured fall within normal limits. Therefore, the respiratory rate should ideally be 16 to 20 breaths/min, the oxygen saturation should be greater than 95%, and the breath sounds should be clear. The correct option is the only one that meets all 3 criteria.

The nurse is trying to communicate with a client who had a stroke and has aphasia. Which actions by the nurse would be most helpful to the client? Select all that apply. Speaking to the client at a slower rate Allowing plenty of time for the client to respond Completing the sentences that the client cannot finish Looking directly at the client during attempts at speech Shouting words if it seems as though the client has difficulty understanding

Speaking to the client at a slower rate Allowing plenty of time for the client to respond Looking directly at the client during attempts at speech Clients with aphasia after brain attack often fatigue easily and have a short attention span. General guidelines when trying to communicate with the aphasic client include speaking more slowly and allowing adequate response time, listening to and watching attempts to communicate, and trying to put the client at ease with a caring and understanding manner. The nurse would avoid shouting (because the client is not deaf), appearing rushed for a response, and letting family members provide all responses for the client.

A client who had a stroke (brain attack) has right-sided hemianopsia. What should the nurse plan to do to help the client adapt to this problem? Teach the client to scan the environment. Place all objects within the left visual field. Place all objects within the right visual field. Ensure that the family brings the client's eyeglasses to hospital.

Teach the client to scan the environment. Hemianopsia is blindness in half of the visual field. The client with hemianopsia is taught to scan the environment. This allows the client to take in the entirety of the visual field, which is necessary for proper functioning within the environment and helps to prevent injury to the client. Options 2 and 3 will not help the client adapt to this visual impairment. Eyeglasses are useful if the client already wears them, but they will not correct this visual field deficit.

The nurse is reviewing the medical records of a client admitted to the nursing unit with a diagnosis of a thrombotic brain attack (stroke). The nurse would expect to note that which is documented in the assessment data section of the record? Sudden loss of consciousness occurred. Signs and symptoms occurred suddenly. The client experienced paresthesias a few days before admission to the hospital. The client complained of a severe headache, which was followed by sudden onset of paralysis.

The client experienced paresthesias a few days before admission to the hospital. Cerebral thrombosis does not occur suddenly. In the few hours or days preceding a thrombotic brain attack (stroke), the client may experience a transient loss of speech, hemiplegia, or paresthesias on 1 side of the body. Signs and symptoms of thrombotic brain attack (stroke) vary but may include dizziness, cognitive changes, or seizures. Headache is rare, but some clients with stroke (brain attack) experience signs and symptoms similar to those of cerebral embolism or intracranial hemorrhage.

The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply. The client is aphasic. The client has weakness on the right side of the body. The client has complete bilateral paralysis of the arms and legs. The client has weakness on the right side of the face and tongue. The client has lost the ability to move the right arm but is able to walk independently. The client has lost the ability to ambulate independently but is able to feed and bathe herself or himself without assistance.

The client is aphasic. The client has weakness on the right side of the body. The client has weakness on the right side of the face and tongue. Hemiparesis is a weakness of one side of the body that may occur after a stroke. It involves weakness of the face and tongue, arm, and leg on one side. These clients are also aphasic, unable to discriminate words and letters. They are generally very cautious and get anxious when attempting a new task. Complete bilateral paralysis does not occur in hemiparesis. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating.

The nurse is creating a plan of care for a client with a diagnosis of stroke (brain attack). On reviewing the client's record, the nurse notes an assessment finding of anosognosia. The nursing care plan should address which manifestation related to this finding? The client will be easily fatigued. The client will have difficulty speaking. The client will have difficulty swallowing. The client will exhibit neglect of the affected side.

The client will exhibit neglect of the affected side. In anosognosia, the client neglects the affected side of the body. The client either may ignore the presence of the affected side (often creating a safety hazard as a result of potential injuries) or may state that the involved arm or leg belongs to someone else. The remaining options are not associated with anosognosia.

The nurse is caring for a client who was admitted for a stroke (brain attack) of the temporal lobe. Which clinical manifestations should the nurse expect to note in the client? The client will be unable to recall past events. The client will have difficulty understanding language. The client will have difficulty moving 1 side of the body. The client will demonstrate difficulty articulating words.

The client will have difficulty understanding language. Wernicke's area consists of a small group of cells in the temporal lobe, the function of which is the understanding of language. The hippocampus is responsible for the storage of memory (the client will be unable to recall past events). Damage to Broca's area is responsible for aphasia (the client will demonstrate difficulty articulating words). The motor cortex in the precentral gyrus controls voluntary motor activity (the client will have difficulty moving one side of the body).

The nurse is creating a plan of care for a client with dysphagia following a stroke (brain attack). Which should the nurse include in the plan? Select all that apply. Thicken liquids. Assist the client with eating. Assess for the presence of a swallow reflex. Place the food on the affected side of the mouth. Provide ample time for the client to chew and swallow.

Thicken liquids. Assist the client with eating. Assess for the presence of a swallow reflex. Provide ample time for the client to chew and swallow. Liquids are thickened to prevent aspiration. The nurse should assist the client with eating and place food on the unaffected side of the mouth. The nurse should assess for gag and swallowing reflexes before the client with dysphagia is started on a diet. The client should be allowed ample time to chew and swallow to prevent choking.

A client who has had a stroke (brain attack) has residual dysphagia. When a diet prescription is initiated, the nurse should take which actions? Select all that apply. Giving the client thin liquids Thickening liquids to the consistency of oatmeal Placing food on the unaffected side of the mouth Allowing plenty of time for chewing and swallowing Leave the client alone so that the client will gain independence by feeding self

Thickening liquids to the consistency of oatmeal Placing food on the unaffected side of the mouth Allowing plenty of time for chewing and swallowing The client with dysphagia is started on a diet only after the gag and swallow reflexes have returned. The client is assisted with meals as needed and is given ample time to chew and swallow. Food is placed on the unaffected side of the mouth. Liquids are thickened to avoid aspiration. The client is not left alone because of the risk of aspiration.

The nurse has completed client teaching on use of thrombolytic medications in acute ischemic stroke. The nurse determines that the educational session was effective if the client states that thrombolytics are used for what purpose? To dissolve clots To prevent ischemia To prevent bleeding To decrease anxiety

To dissolve clots Thrombolytic medications are used to treat acute thrombolytic disorders. These medications dissolve clots. Because these medications alter the hemostatic capability of the client, any bleeding that does occur can be difficult to control. Options 2, 3, and 4 are not actions of this medication.

The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? "We need to discourage him from wearing eyeglasses." "We need to place objects in his impaired field of vision." "We need to approach him from the impaired field of vision." "We need to remind him to turn his head to scan the lost visual field."

We need to remind him to turn his head to scan the lost visual field." Homonymous hemianopsia is loss of half of the visual field. The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse also should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision. The nurse encourages the use of personal eyeglasses, if they are available.