Deck 23: Cerebrovascular Accident

Question 1

What should a nurse ensure as a priority for a patient immediately after a CVA?

A) Preservation of motor function
B) Airway maintenance
C) Adequate hydration
D) Control of elimination

Answer 1

Airway maintenance

Question 2

A nurse explains that a lumbar puncture is most helpful as a diagnostic tool for a new patient who has had a CVA.What would this diagnostic test help determine regarding the stroke?

A) It is lacunar.
B) It is hemorrhagic or embolic.
C) It is complete or in evolution.
D) It will result in paralysis.

Answer 2

It is hemorrhagic or embolic.

Question 3

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?

A) Give the full dose as prescribed without further assessment.
B) Omit the dose, recording the pulse rate as the rationale.
C) Delay the dose until the pulse is below 60 beats/min.
D) Give half of the prescribed dose (30 mg).

Answer 3

Give the full dose as prescribed without further assessment.

Question 4

A nurse is updating a teaching plan for a patient who sustained a TIA.What should the nurse be sure to include?

A) Daily aspirin dose
B) Long rest periods daily
C) Reduction of fluid intake to 800 mL/day
D) High-carbohydrate diet

Question 5

A patient experienced a period of momentary confusion, dizziness, and slurred speech but recovered in 2 hours.Which assessment in the diagnosis of this episode would be most helpful?

A) Patient's complaint of nausea
B) Blood pressure (BP)of 140/90 mm Hg
C) Patient's complaint of headache
D) Results of MRI

Question 6

Which assessment indicates that a patient with a CVA is in transition to the rehabilitation phase?

A) BP has been within normal limits for 24 hours.
B) Patient makes positive statements about his condition.
C) No further neurologic deficits are observed.
D) Successful attempts are made at independent function.

Question 7

A patient has had a complete stroke as a result of a ruptured vessel in the left hemisphere.How should this patient's CVA be classified?

A) Ischemic, embolic
B) Hemorrhagic, subarachnoid
C) Hemorrhagic, intracerebral
D) Ischemic, thrombotic

Question 8

A patient has weakness on the right side and impaired reasoning after having a cerebrovascular accident (CVA).What part of the brain is affected?

A) Left hemisphere of the cerebrum
B) Right hemisphere of the cerebrum
C) Left cerebellum
D) Right cerebellum

Question 9

Which patient is at the greatest risk for a CVA?

A) A 20-year-old obese Latin woman who is taking birth control pills
B) A 40-year-old athletic white man with a family history of CVA
C) A 60-year-old Asian woman who smokes occasionally
D) A 65-year-old African-American man with hypertension

Question 10

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?

A) Dissolves the clot
B) Prevents the formation of new clots
C) Dilates the vessels to improve blood flow
D) Suppresses the formation of platelets

Question 11

During the acute CVA phase, a risk for falls related to paralysis is present.Which intervention best protects the patient from injury?

A) Keep the bed in a high position for ease of nursing care.
B) Keep the side rails up, according to agency policy.
C) Assess vision deficit related to ptosis.
D) Monitor the condition every 2 hours.

Question 12

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?

A) Stroke in evolution with dysarthria
B) Lacunar stroke with fluent aphasia
C) Complete stroke with global aphasia
D) Stroke in evolution with dyspraxia

Question 13

A patient in the acute phase of an embolic CVA has an order for 400 units of heparin per hour IV.The heparin is in a solution of 5000 units/100 mL normal saline (NS).The nurse should set the electronic IV monitor at how many milliliters per hour?

A) 6
B) 8
C) 10
D) 16

Question 14

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?

A) Thicken liquids to ease swallowing and prevent aspiration.
B) Change position every 30 to 60 minutes.
C) Maintain adequate fluid intake, orally or IV.
D) Encourage forceful coughing to stimulate deep breathing.

Question 15

Which assessment indicates a fluid volume excess in a patient in the acute phase of a CVA?

A) Decreased BP
B) Weak pulse
C) Adventitious breath sounds
D) High urine-specific gravity

Question 16

Which intervention should the nurse include in a patient's plan of care to help preserve joint mobility in the acute phase of a CVA?

A) Pull the limbs on the affected side into a functional position.
B) Perform aggressive full range-of-motion exercises for all extremities.
C) Support affected points in good functional alignment.
D) Exercise the limbs every 8 hours.

Question 17

Which outcome criterion is the most appropriate for a patient with "Inadequate nutrition, related to dysphagia, with the goal of adequate intake of nutrients"?

A) Offers a variety of food groups
B) Eats half of all meals offered
C) Maintains body weight of 150 to 155 lb
D) Eats all meals independently

Question 18

When should a nurse recognize that the acute phase of a CVA has ended?

A) Forty-eight hours has passed from its onset.
B) The patient begins to respond verbally.
C) BP drops.
D) Vital signs and neurologic signs stabilize.

Question 19

Several days after a CVA, a patient's family asks a nurse if tissue plasminogen activator (tPA)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?

A) 3
B) 5
C) 10
D) 24

Question 20

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?

A) Unaffected side
B) Affected side
C) Direct front
D) Either side

Question 21

Which transitory symptoms might occur when a patient is diagnosed with a TIA? (Select all that apply.)

A) Incontinence
B) Dysphagia
C) Ptosis
D) Tinnitus
E) Dysarthria

Question 22

What purposes exist for a stent in the carotid artery of a person with a TIA?

A) Capture circulating clots.
B) Help with subsequent angioplasties.
C) Keep the artery open.
D) Prevent hemorrhage.
E) Measure the pressure in the artery.

Question 23

Approximately 30% of individuals who experience a TIA have a stroke within ______ years.(Use numeric characters only.)

Question 24

Which is the most effective intervention for best support of regular bowel elimination and the prevention of constipation?

A) Limit fluid intake from 32 to 50 oz daily to compact the stool.
B) Administer small soapsuds enema every other day to cleanse the bowel.
C) Give stool softeners daily, establishing a consistent time to attempt elimination.
D) Administer a strong laxative on a daily basis to encourage evacuation.

Question 25

How does a lacunar stroke differ from an ischemic CVA? (Select all that apply.)

A) Causes a great deal of pain
B) Alters the personality
C) Affects small arteries
D) Nearly always results in blindness
E) Produces a small amount of neurologic damage

Question 26

A patient in the rehabilitation phase after a CVA accidentally knocks the adapted plate from the table and bursts into tears after failing to feed himself.What is the best response by the nurse?

A) "Don't cry.You'll be mastering eating in no time."
B) "I don't believe crying will help.Let's try drinking from a special cup."
C) "Bless your heart! Let me get a new meal and feed you."
D) "Learning new skills is hard.Let's see what may have caused the trouble."

Question 27

Which patients with CVAs are considered candidates for treatment with tPA? (Select all that apply.)

A) A 62-year-old construction worker who had a subdural hematoma 6 months earlier
B) A 58-year-old executive with a bleeding ulcer
C) A 44-year-old individual who had a seizure at the onset of a stroke
D) A 40-year-old individual who is taking warfarin (Coumadin)and has an INR of 2.5
E) A 19-year-old young adult with leukemia with a platelet count of 200,000

Question 28

Which home modifications will support rehabilitation for a patient who had a stroke? (Select all that apply.)

A) Raised commode seat
B) Provision of a seat in the shower
C) Availability of soft, low chairs
D) Bathtub handrails
E) Bright-colored scatter rugs

Question 29

Which posthospital option should the nurse encourage a patient to do when recovering from a CVA to provide the most comprehensive assistance?

A) Transfer to a rehabilitation center.
B) Discharge to home with scheduled visits from home health care nurses.
C) Discharge to home with scheduled visits from a physical therapist.
D) Discharge to home with scheduled visits from an occupational therapist.

Question 30

What signs and symptoms characterize expressive aphasia?

A) Speech that sounds normal but makes no sense
B) Total inability to communicate
C) Difficulty understanding the written and spoken word
D) Stuttering and spitting
E) Difficulty initiating speech

Question 31

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?

A) Brain swelling
B) Hypertension
C) Immobility
D) Stress

Question 32

Which instruction is most helpful in teaching the family and patient who is in the rehabilitation phase after a CVA about altered sensation?

A) Make frequent assessments for signs of pressure or injury.
B) Use the affected side in supporting the patient in ambulation and transfer to stimulate better sensation.
C) Apply ice packs to the affected limbs to encourage a return of sensation.
D) Apply a heating pad to the affected limbs to increase circulation.

Question 33

What causes the 5% of strokes known to occur in persons younger than 45 years of age? (Select all that apply.)

A) Drug abuse
B) Alcohol abuse
C) Birth control pills
D) Sickle cell anemia
E) Hemophilia