These Questions
A patient has weakness on the right side and impaired reasoning after having a cerebrovascular accident (CVA). What part of the brain is affected?
Left hemisphere of the cerebrum
Rationale: Impaired motor strength on the right side in conjunction with impaired reasoning indicates a lesion in the left hemisphere of the cerebrum. The cerebellum controls balance and is not contralateral.
What signs and symptoms characterize expressive aphasia? (Select all that apply.)
Rationale: Expressive aphasia has difficulty speaking and writing. Aphasia can also be classified as fluent and nonfluent. The patient who has fluent aphasia sounds normal but makes little sense whereas the person with nonfluent aphasia has difficulty initiating speech.
Which instruction is most helpful in teaching the family and patient who is in the rehabilitation phase after a CVA about altered sensation?
Rationale: Frequent assessment using the National Institutes of Health Stroke Scale will allow early detection. The use of hot or cold applications and using the affected limbs in transfer or ambulation may cause injury.
What purposes exist for a stent in the carotid artery of a person with a TIA?
Rationale: The only purpose of a stent is to keep an artery open.
Several days after a CVA, a patient’s family asks a nurse if tissue plasminogen activator (rt-PA) is a drug therapy option now. The nurse’s response is based on the knowledge that this drug must be used within how many hours after the onset of symptoms?
Rationale: tPA is to be given within 3 hours of the onset of symptoms per the U.S. Food and Drug Administration’s guidelines. In some special treatment centers this drug is given intravenously up to 6 hours after the stroke.
A nursing is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate with the client. Which of the following is an appropriate response by the nurse?
1) "Incorporate nonverbal cues in the conversation."
2) "Ask multiple choice questions as part of the conversation."
3) "Use a higher-pitched tone of voice when speaking."
4) "Use simple child-like statements when speaking."
1) "Incorporate nonverbal cues in the conversation."
Answer Rationale:
The nurse should remind the family to use nonverbal cues to enhance the client’s ability to comprehend and use language.
A nurse is caring for a client who had a stroke and has dysphagia. The nurse should monitor the client for which of the following complications?
1. Aspiration
2. Peptic ulcer disease
3. Gastroesophageal reflux disease
4. Dumping syndrome
Aspiration
Client who have dysphagia are at risk for aspiration pneumonia. The nurse should monitor the client for fever and adventitious breath sounds.
A patient in the acute phase of a CVA who has been speaking distinctly begins to speak indistinctly and only with great effort but still coherent. What should this nurse determine when assessing this patient?
Rationale: As symptoms worsen, the CVA is still evolving. Speech that is coherent but difficult is dysarthria rather than any type of aphasia. Dyspraxia is a motor impairment, not a speech impairment.
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A patient recovering from a CVA asks the purpose of the warfarin (Coumadin). What is the best response by the nurse regarding the purpose of Coumadin?
Prevents the formation of new clots.
Rationale: Coumadin and heparin prevent more clots rather than dissolving them. Coumadin has no effect on vasodilation or blood cell production.
A lacunar stroke differs from an ischemic CVA in the following ways. A lacunar stroke: (Select all that apply.)
Rationale: The lacunar CVA only affects small arteries and produces a small amount of neurologic damage. Medical-Surgical Nursing 7th ed ch 23 p. 403
A nurse is reinforcing teaching to a female client who has risk factors for stroke. Which of the following statements by the client indicates an understanding of the teaching?
1) "Using oral contraceptives provides me with protection from a stroke."
2) "I can safely have up to 3 alcoholic drinks a day."
3) "Managing my cholesterol will reduce my chances of having a stroke."
4) "My blood pressure needs to stay a little elevated for good blood flow to my brain."
3) "Managing my cholesterol will reduce my chances of having a stroke."
Answer Rationale:
The client shows understanding of the teaching with this statement, as controlling cholesterol is an intervention to reduce the risk of stroke.
A nurse is caring for an older client who has dysphagia and left-sided weakness following a stroke. Which of the following actions should the nurse take?
Serve food at room temperature
Rationale: The nurse should thicken fluids to make them easier to swallow and prevent aspiration.
The nurse is caring for a patient who has an initial diagnosis of transient ischemic attack (TIA). The nurse knows that the physician may order which diagnostic examinations to confirm this diagnosis?
Rationale: A suspected TIA is based on physical examination and health history. To confirm, brain imaging studies, preferably with an MRI, are required. EEG and CT scan can be used to rule out aneurysms, abscesses, and tumors (intracranial lesions). An ECG records the electrical activity of the heart and is not used to confirm TIA.
A patient who has sustained a hemorrhagic stroke is placed on a protocol of 60 mg of calcium channel blocker (nimodipine) every 4 hours. The patient’s pulse is 82 beats/min before the administration of the prescribed dose. Which action should the nurse implement?
Rationale: The dose should be given; it would be held only if the pulse is below 60 beats/min. Assessments should be made regarding BP, urine output, and edema.
A patient has had a complete stroke as a result of a ruptured vessel in the left hemisphere of the cerebrum. How should this patient’s CVA be classified?
Rationale: A ruptured vessel in a hemisphere is an intracerebral hemorrhagic CVA. It did not occur in the subarachnoid space. Ischemic CVAs are the result of occluded vessels.
An older adult client in a long-term care facility had a stroke 4 weeks ago and has been unable to move independently since that time. The nurse caring for her should observe for which of the following findings that indicates a complication of immobility?
1) A reddened area over the sacrum
2) Stiffness in the lower extremities
3) Difficulty moving the upper extremities
4) Difficulty hearing some types of sounds
1) A reddened area over the sacrum
Answer Rationale:
A reddened area over a bony prominence is a stage 1 pressure ulcer, a complication of immobility. If the nurse recognizes it at this stage and implements measures to avoid additional pressure, it might not progress to the next stage.
Pneumonia is the most frequent cause of death after a stroke. Which intervention would be contraindicated in the acute care of a patient with a hemorrhagic CVA?
Rationale: Forceful coughing is contraindicated for the patient with a hemorrhagic CVA because it may cause increased intracranial pressure.
A nurse is caring for a client who is recovering from a stroke. Which of the following information should the nurse include when reinforcing teaching with members of the client?s family about repositioning the client? (Select all that apply.)
1. Face the direction of movement when repositioning the client.
2. Elevate the bed to waist height.
3. Remove pillows prior to repositioning.
4. Stand with their feet wide apart.
5. Position the client toward the edge of the bed on the side the client will face after turning.
1. Face the direction of movement when repositioning the client.
2. Elevate the bed to waist height.
3. Remove pillows prior to repositioning.
4. Stand with their feet wide apart.
Rationale:
Remove pillows prior to repositioning is correct. The family caregivers should remove pillows that are supporting the client and then place one against the head of the bed. This prevents injury from the client?s head striking the headboard when the family members pull the client up in bed.
Elevate the bed to waist height is correct. Working at waist height promotes ergonomics and minimizes the risk of injury to the individuals performing repositioning maneuvers and to the client.
Position the client toward the edge of the bed on the side the client will face after turning is incorrect. The family caregivers should position the client toward the side of the bed opposite the side the client will face after turning. This action will help the client to be in the center of the bed after repositioning.
Stand with their feet wide apart is correct. A wide base of support when moving a client facilitates movement and minimizes the risk of injury to individuals performing repositioning maneuvers. The body?s center of gravity is the pelvis. The closer the center of gravity is to the base of support, the more stable the movement. A wide stance achieves this.
Face the direction of movement when repositioning the client is correct. When repositioning a client, family members should move their rear leg back to promote ergonomic stability. Facing the direction of movement maintains alignment for both the client and the caregivers. This prevents straining back muscles or bending at the waist. Sliding, rolling, and pushing in the same direction that the caregivers face require less energy and pose less risk for injury.
The wife of a husband who has had a CVA asks why he is being treated with insulin since he has no history of diabetes. What is the best response by the nurse as to why hyperglycemia occurs after a stroke?
Rationale: Hyperglycemia occurs after a CVA as the body’s response to stress. If left untreated, the hyperglycemia will cause increased brain damage and worsen the outcome of the stroke.
A patient with homonymous hemianopsia is in the rehabilitation phase of a CVA. When arranging this patient’s environment where should the nurse assure persons approaching and important items are visible and available?
Rationale: Making the patient scan the affected side helps stimulate the return of normal function in the rehabilitation phase.
Which transitory symptoms might occur when a patient is diagnosed with a TIA? (Select all that apply.)
Rationale: All, except transitory incontinence, are classic symptoms of a TIA. These deficits usually disappear without permanent disability in approximately 24 hours.
A nurse is reviewing the lab results of a patient who is taking warfarin to reduce the risk of stroke. The PT is 12, and he INR is 1. What is the nurse's BEST action?
Rationale: The PT of 11.0 to 12.6 seconds and the INR of 1 to 1.2 are within normal limits, so no further action is needed unless the care provider has specifically instructed to do so. The results of the PT and INR do not demonstrate increased risk for bleeding.
A nurse is performing a home safety assessment for a client who has experienced a stroke. Which of the following findings are a safety hazards for the client? (Select All that Apply.)
1. Dim lighting installed throughout the house.
2. Grab bars are installed in the bathroom.
3. The hot water heater is set at 54ºC (130º F).
4. Medications are stored in a clear bag.
5. Area rugs are placed in the living room.
1. Dim lighting installed throughout the house.
3. The hot water heater is set at 54ºC (130º F).
4. Medications are stored in a clear bag.
5. Area rugs are placed in the living room.
Rationale:
Dim lighting installed throughout the house is correct. The nurse should identify that dim lighting is a safety hazard for clients especially if their vision is impaired or if they have cataracts. Bright lighting should be installed in place of the dim lighting.
The hot water heater is set at 54ºC (130º F) is correct. The nurse should identify the client’s hot water being set to 54º C (130º F) is a safety hazard because it is too hot and could burn the client. The client’s hot water heater should be set to 49º C (120º F).
Medications are stored in a clear bag is correct. The nurse should identify that the client’s medications being stored in a clear bag is a safety hazard. The client’s medications should be placed in a pill container, such as a medication reminder that labels the dates and even times at which the client should take their medications.
Grab bars are installed in the bathroom is incorrect. Grab bars being installed in the client’s bathroom helps to prevent the client from falling. This is not a safety hazard.
Area rugs are placed in the living room is correct. The nurse should identify that area rugs being placed in the client’s living room is a safety risk because they could cause the client to trip and fall. The area rugs need to be removed or tacked to the floor to help protect the client from injury.
A patient is being treated with dexamethasone (Decadron) after experiencing a cerebrovascular accident. What is the HIGHEST priority nursing action while the patient is being treated with this medication?
Rationale: Although all of the interventions are important and should be implemented, the highest priority intervention would be to report any evidence of infection, which could be a life-threatening event to this patient. The nurse should also monitor the patient’s intake and output because of the medication’s tendency to cause fluid retention. The patient’s laboratory results should also be monitored because of the medication’s tendency to cause hypokalemia. The medication does have the tendency to cause hypertension, so the patient’s blood pressure should also be monitored.