Test 3 Chpt 67,70

A home care nurse makes a visit to a client with Parkinson's disease who is being cared for by his spouse. During the visit, the spouse says, "I'm just so tired. I have to do just about everything for him." Which response by the nurse would be most appropriate?

"It must be difficult for you to see your husband like this." "Are you upset about how your husband is doing?" "You're doing a great job. Just keep it up." ***"You sound a bit overwhelmed. Tell me more about what's happening."

A client who has experienced an initial transient ischemic attack (TIA) states: "I'm glad it wasn't anything serious." Which is the best nursing response to this statement?

"People who experience a TIA will develop a stroke". "TIA symptoms are short-lived and resolve within 24 hours". "I sense that you are happy it was not a stroke". ***"TIA is a warning sign. Let's talk about lowering your risks."

A client with Parkinson's disease asks the nurse what their treatment is supposed to do since the disease is progressive. What would be the nurse's best response?

***"Treatment aims at keeping you independent as long as possible." "Treatment for Parkinson's is only palliative; it keeps you comfortable." "Treatment really doesn't matter; the disease is going to progress anyway." "Treatment aims at keeping you emotionally healthy by making you think you are doing something to fight this disease."

Thrombolytic therapy should be initiated within what time frame of an ischemic stroke to achieve the best functional outcome?

***3 hours 6 hours 9 hours 12 hours

A patient suffering a stroke is having a difficult time swallowing. What would the nurse document this finding as?

***Dysphagia Arthralgia Dysarthria Ataxia

A nurse is providing education to a community group about ischemic strokes. One group member asks if there are ways to reduce the risk for stroke. Which of the following is a risk factor that can be modified?

***Hypertension Male gender Advanced age African heritage

A client with CVA is prescribed medication to treat the disorder. The client wants to know what other measures may help reduce CVA. Which is an accurate suggestion for the client?

***Reduce hypertension and high blood cholesterol Increase body weight moderately Increase hydration and the intake of fluids Increase intake of proteins and carbohydrates

A nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform?

Administer an analgesic. Inform the nurse manager. Sit with the client for a few minutes. ***Call the physician immediately.

A client with Parkinson's disease has been receiving levodopa as treatment for the past 7 years. The client comes to the facility for an evaluation and the nurse observes facial grimacing, head bobbing, and smacking movements. The nurse interprets these findings as which of the following?

Bradykinesia Micrographia Dysphonia ***Dyskinesia

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 Atorvastatin ***Tissue plasminogen activator (tPA)

A nurse is caring for an older client who has had a hemorrhagic stroke. The client has exhibited impulsive behavior and, despite reminders from the nurse, doesn't recognize his limitations. Which priority measure should the nurse implement to prevent injury?

Encourage the client to do as much as possible without assistance, and to use the call light only in emergencies. Encourage the family to reprimand the client if he doesn't ask for help with transfers and mobility. Ask a physician to order a vest and wrist restraints. ***Install a bed alarm to remind the client to ask for assistance and to alert staff that the client is getting out of bed.

The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration?

Generalized pain ***Alteration in level of consciousness (LOC) Tonic-clonic seizures Shortness of breath

The client has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the client's atmosphere more conducive to communication?

Help the client complete his or her sentences as needed. ***Provide a board of commonly used needs and phrases. Have the client speak to loved ones on the phone daily. Speak in a loud and deliberate voice to the client.

A client is brought to the emergency department with symptoms of a cerebrovascular accident (CVA). The nurse would anticipate which diagnostic evaluation to be completed prior to initiation of treatment?

Lumbar puncture Chest x-ray ***Brain CT scan or MRI Prothrombin level

A client with a neurological disorder has difficulty swallowing. The nurse should take special care with the client's diet because of a potential risk of imbalanced nutrition. Which measure may be taken by the nurse to ensure that the client's diet allows for easy swallowing?

Offer liquids frequently, in large quantities ***Help the client sit upright when eating and feed slowly Allow optimum physical activity before meals to expedite digestion Instruct the client to lie on the bed when eating

A client who just experienced a suspected ischemic stroke is brought to the ED by ambulance. On what should the nurse's primary assessment focus?

Pain ***Cardiac and respiratory status Seizure activity Fluid and electrolyte balance

The nurse is assessing a client with a suspected stroke. What assessment finding is most suggestive of a stroke?

Periorbital edema Dysrhythmias ***Facial droop Projectile vomiting

Health promotion efforts to decrease the risk for ischemic stroke involve encouraging a healthy lifestyle including

a high-protein diet and increased weight-bearing exercise. eating fish no more than once a month. a low-cholesterol, low-protein diet and decreased aerobic exercise. ***a low-fat, low-cholesterol diet and increased exercise.

A white female client is admitted to an acute care facility with a diagnosis of stroke. Her history reveals bronchial asthma, exogenous obesity, and iron-deficiency anemia. Which history finding is a risk factor for stroke?

***Being obese Being female Being white Having bronchial asthma

A client is following up after a visit to the emergency department where testing indicated that the client had suffered a transient ischemic attack. What lifestyle changes would the nurse include in teaching to prevent further reoccurrence? Select all that apply.

***Blood pressure control Physical activity limitations ***Weight loss High-dose aspirin ***Smoking cessation

A client has just been diagnosed with Parkinson disease and the nurse is planning the client's subsequent care for the home setting. What nursing diagnosis should the nurse address when educating the client's family?

***Risk for injury Risk for infection Impaired spontaneous ventilation Unilateral neglect

Which interventions would be recommended for a client with dysphagia? Select all that apply.

***Test the gag reflex before offering food or fluids. Place food on the affected side of the mouth. ***Allow ample time to eat. ***Assist the client with meals.

Which topic is most important for the nurse to include in the teaching plan for a client newly diagnosed with Parkinson's disease?

Involvement with diversion activities ***Maintaining a safe environment Enhancement of the immune system Establishing balanced nutrition

Which are contraindications for the administration of tissue plasminogen activator (t-PA)? Select all that apply.

Systolic BP less than or equal to 185 mm Hg ***Intracranial hemorrhage ***Major abdominal surgery within 10 days Age 18 years or older Ischemic stroke

The nurse is caring for a patient with Parkinson's disease and is preparing to administer medication. What does the nurse administer to the patient that is considered the most effective drug currently given for the tremor of Parkinson's?

Requip Symmetrel Permax ***Levodopa

The nurse plays a critical role in the initial work-up of a patient with acute stroke symptoms. An immediate decision is to determine if the stroke is ischemic or hemorrhagic. Although there is overlap in some motor, sensory, and cognitive changes, hemorrhagic strokes can be identified by some specific signs. Which of the following signs are consistent with a hemorrhagic stroke? Select all that apply.

***Vomiting Loss of balance Numbness or weakness of an extremity ***Sudden, severe headache ***Seizures

A critical care nurse is caring for a client with a cerebrovascular accident (CVA) The client is prescribed heparin for treatment. The nurse knows to monitor the client for what adverse effects?

Migraine attacks High blood pressure ***Hemorrhage Respiratory distress

Which of the following is the chief cause of intracerebral hemorrhage (ICH)?

Migraine headaches ***Uncontrolled hypertension Hypercholesterolemia Diabetes

A nurse is providing care to a client with Parkinson's disease. The nurse understands the client's signs and symptoms are related to a depletion of which of the following?

Serotonin Norepinephrine ***Dopamine Acetylcholine