PN 140 CVA
The nurse is assigned to care for an adult client who had a stroke and is aphasic. Which interventions should the nurse use for communicating with the client? Select all that apply 1. Face the client when talking. 2. Speak slowly and maintain eye contact. 3. Use gestures when talking to enhance words. 4. Avoid the use of body language when talking to the client. 5. Give the client directions using short phrases and simple terms. 6. Phrase what was said differently the second time, if there is a need to repeat it.
1, 2, 3, 5 A client who is aphasic has difficulty expressing or understanding language. The nurse should face the client when talking, establish and maintain eye contact, and speak slowly and distinctly. The nurse should use gestures and pantomime when talking to enhance words and use body language to enhance the message. The nurse should give the client directions using short phrases and simple terms, and phrase questions so that they can be answered with a yes or no. If there is a need to repeat something, the nurse should use the same words a second time.
A client with a stroke (brain attack) has residual dysphagia. When a diet prescription is initiated, the nurse should avoid which action? 1. Giving the client thin liquids 2. Thickening liquids to the consistency of oatmeal 3. Placing food on the unaffected side of the mouth 4. Allowing plenty of time for chewing and swallowing
1. Giving the client thin liquids Before the client with dysphagia is started on a diet, the gag and swallow reflexes must 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.
A client with a stroke (brain attack) is experiencing residual dysphagia. The nurse should remove which food items that arrived on the client's meal tray from the dietary department? 1.Peas 2.Scrambled eggs 3.Mashed potatoes 4.Cheese casserole
1. Peas In general, flavorful, very warm, or well-chilled foods with texture stimulate the swallowing reflex. Moist pastas, casseroles, egg dishes, and potatoes are usually well tolerated. Raw vegetables; chunky vegetables such as diced beets; and stringy vegetables such as spinach, corn, and peas are commonly excluded from the diet of a client with a poor swallowing reflex.
What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? 1. Cholesterol level 2. Pupil size and pupillary response 3. Bowel sounds 4. Echocardiogram
2. Pupil size and pupillary response It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves. Pupil reactions are regulated by the oculomotor (III) cranial nerve and are useful in determining whether the brain stem is intact. Pupil size and equality is determined by a balance between parasympathetic and sympathetic innervation. Response to light reflects the combined function of the optic (II) and oculomotor (III) cranial nerves.
During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to control the client's: 1. Pulse 2. Respirations 3. Blood pressure 4. Temperature
3. Blood pressure Controlling the blood pressure is critical because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy. Blood pressure should be maintained according to the physician and is specific to the client's ischemic tissue needs and risks of bleeding from treatment. Other vital signs are monitored, but the priority is blood pressure.
The nurse is trying to communicate with a stroke (brain attack) client with aphasia. Which action by the nurse would be least helpful to the client? 1. Speaking to the client at a slower rate 2. Allowing plenty of time for the client to respond 3. Completing the sentences that the client cannot finish 4. Looking directly at the client during attempts at speech
3. Completing the sentences that the client cannot finish Clients with aphasia after stroke 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 should avoid shouting (because the client is not deaf), appearing impatient for a response, and completing responses for the client.
The nurse is preparing a plan of care for a client with a brain attack (stroke) who has global aphasia. The nurse incorporates communication strategies in the plan of care, knowing that the client's speech should fit which characterization? 1. Rambling 2. Difficult to understand 3. Characterized by literal paraphasia 4. Associated with poor comprehension
4. Associated with poor comprehension Global aphasia is a condition in which a 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 the speech is characterized by literal paraphasia with intact comprehension. The client with Wernicke's aphasia may exhibit a rambling type of speech.
The nurse is reinforcing instructions to the family of a stroke client who has homonymous hemianopsia about measures to help the client overcome the deficit. The nurse determines that the family understands the measures to use if they state that they will do which? 1. Place objects in the client's impaired field of vision. 2. Approach the client from the impaired field of vision. 3. Discourage the client from wearing his or her own eyeglasses. 4.Remind the client to turn the head to scan the lost visual field.
4. Remind the client to turn the 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 should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and performs client teaching from within the intact field of vision. The nurse encourages the use of personal eyeglasses if they are available.
What is the expected outcome of thrombolytic drug therapy? 1. Increased vascular permeability 2. Vasoconstriction 3. Dissolved emboli 4. Prevention of hemorrhage
3. Dissolved emboli Thrombolytic therapy is used to dissolve emboli and reestablish cerebral perfusion. Thrombolytic treatment is also known as fibrinolytic or thrombolysis, to dissolve dangerous intravascular clots to prevent ischemic damage by improving blood flow. Thrombosis is a significant physiological response that limits hemorrhage caused by large or tiny vascular injury.
Which client would the nurse identify as being most at risk for experiencing a CVA? 1. A 39-year-old pregnant female. 2. A 67-year-old Caucasian male. 3. An 84-year-old Japanese female. 4. A 55-year-old African American male.
4. A 55-year-old African American male. African Americans have twice the rate of CVAs as Caucasians; males are more likely to have strokes than females except in advanced years. Of all the risk factors, hypertension is the most common modifiable risk factor for stroke. Hypertension is most prevalent in African-Americans and also occurs earlier in life.
Regular oral hygiene is an essential intervention for the client who has had a stroke. Which of the following nursing measures is inappropriate when providing oral hygiene? 1. Placing the client on the back with a small pillow under the head. 2. Keeping portable suctioning equipment at the bedside. 3. Opening the client's mouth with a padded tongue blade. 4. Cleaning the client's mouth and teeth with a toothbrush.
1. Placing the client on the back with a small pillow under the head. A helpless client should be positioned on the side, not on the back. This lateral position helps secretions escape from the throat and mouth, minimizing the risk of aspiration. Observe the patient for paroxysms of coughing, food dribbling out or pooling in one side of the mouth, food retained for long periods in the mouth, or nasal regurgitation when swallowing liquids.
A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. Which is the priority nursing assessment? 1. Time of onset of current stroke 2. Complete physical and history 3. Current medications 4. Upcoming surgical procedures
1. Time of onset of current stroke The time of onset of a stroke to t-PA administration is critical. Administration within 3 hours has better outcomes. Tissue plasminogen activator (tPA) is classified as a serine protease (enzymes that cleave peptide bonds in proteins). It is thus one of the essential components of the dissolution of blood clots. Its primary function includes catalyzing the conversion of plasminogen to plasmin, the primary enzyme involved in dissolving blood clots.
The nurse is planning care for the client with hemiparesis of the right arm and leg. Where should the nurse plan to place objects needed by the client? 1. Within the client's reach, on the left side 2. Within the client's reach, on the right side 3. Just out of the client's reach, on the left side 4. Just out of the client's reach, on the right side
1. Within the client's reach, on the left side Hemiparesis is a weakness of the face, arm, and leg on one side. The client with one-sided hemiparesis benefits from having objects placed on the unaffected side and within reach. Other helpful activities with hemiparesis include range-of-motion exercises to the affected side and muscle-strengthening exercises to the unaffected side.
A client with right leg hemiplegia is experiencing difficulty with mobility. The nurse determines that there is a need for further teaching if the nurse observes which action by the family? 1. Applying a premolded splint 2. Performing active ROM to the affected leg 3. Encouraging the client to stand unassisted on the leg 4. Providing passive range of motion (ROM) to the affected leg
3. Encouraging the client to stand unassisted on the leg The question is worded to elicit an unsafe action on the part of the family. Depending on the client's functional ability, either passive or active ROM is indicated to keep the joint moving freely. Application of a premolded splint would also keep the limb aligned and in good position. The client should not attempt to stand unsupported on a weak or paralyzed limb. The inability to bear weight will cause the client to fall.
A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority? 1. Prepare to administer recombinant tissue plasminogen activator (rt-PA). 2. Discuss the precipitating factors that caused the symptoms. 3. Schedule for A STAT computer tomography (CT) scan of the head. 4. Notify the speech pathologist for an emergency consultation.
3. Schedule for A STAT computer tomography (CT) scan of the head. A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. This would also determine if it is a hemorrhagic or ischemic accident and guide the treatment because only an ischemic stroke can use rt-PA. Demonstrates structural abnormalities, edema, hematomas, ischemia, and infarctions. Demonstrates structural abnormalities, edema, hematomas, ischemia, and infarctions.
The nurse is caring for a client with a diagnosis of right (nondominant) hemispheric brain attack (stroke). The nurse notes that the client is alert and oriented to time and place. Based on these findings, the nurse makes which determination? 1. The client experienced a very mild stroke. 2. The client suffered a transient ischemic attack. 3. The client may have perceptual and spatial disabilities. 4. The client may have difficulty with language abilities only.
3. The client may 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 result in interpretations that the client is less disabled than is the case. However, impulsive actions and confusion in carrying out activities may be very much a problem for these clients as a result of perceptual and spatial disabilities. The right hemisphere is considered specialized in sensory-perceptual and visuospatial processing and awareness of body space. The left hemisphere is dominant for language abilities.
The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? 1. A thrombolytic medication 2. A beta-blocker medication 3. An anti-hyperuricemic medication 4. An oral anticoagulant medication
4. An oral anticoagulant medication Thrombi form secondary to atrial fibrillation. Therefore, an anticoagulant would be anticipated to prevent thrombus formation; and oral (warfarin [Coumadin]) at discharge versus intravenous. Oral anticoagulation is indicated for patients with atrial fibrillation or other sources of cardioembolic sources of TIA.
