Question 1

The nurse selects the most effective intervention for best support of regular bowel elimination and the prevention of constipation,which is:

Accepted Answer

Daily stool softeners,rather than daily laxatives or frequent enemas,help restore regularity and bowel tone.

Question 2

The nurse suspects a TIA has occurred when the assessment of a patient reveals transitory:

Accepted Answer

All,except transitory incontinence,are classic symptoms of a TIA.These deficits usually disappear without permanent disability in approximately 24 hours.

Question 3

The nurse,using the nursing diagnosis,"Imbalanced nutrition,related to dysphagia,with the goal of adequate nutrition," would select the appropriate outcome criterion as:

Accepted Answer

The maintenance of a desired weight is indicative of adequate nutrition.Eating a portion of a meal or eating independently does not adequately measure the extent to which the goal was met.Offering a variety of foods is a nursing or dietary function,not an outcome.

Question 4

The nurse assesses patients with CVAs who are candidates for treatment with tPA.They include a:

Accepted Answer

The criteria for exclusion are a head injury within the last 3 months,a platelet count less than 100,000,active gastrointestinal (GI)bleeding,current treatment with an anticoagulant,and a seizure noted at the time of the CVA.

Question 5

The nurse checks the oxygen in the circulating volume for adequate concentration to support the brain's need of ________% of the oxygen supply of the body.

Accepted Answer

The answer of The nurse checks the oxygen in the...

Question 6

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.The nurse's response is based on the knowledge that hyperglycemia occurs after a stroke as a response to:

Accepted Answer

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.

Question 7

The instruction that is most helpful in teaching the family and patient who is in the rehabilitation phase after a CVA about altered sensation is to:

Accepted Answer

Frequent assessment using the National Institutes of Health (NIH)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.

Question 8

The 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.The nurse's best response would be:

Accepted Answer

Recognizing effort and showing support are the best approaches to depression and frustration.Babying the patient and admonitions against crying add to the problem.Redirection to the task at hand is therapeutic.

Question 9

The nurse prepares a list of home modifications that will support rehabilitation for a patient who had a stroke.These include:

Accepted Answer

A raised commode seat,a seat in the shower,and bathtub rails assist the patient who is recovering from a stroke with self care.Low chairs are difficult to manage,and scatter rugs pose a hazard for falls.

Question 10

The nurse is supportive of the frustrated patient with expressive aphasia because the condition is characterized by:

Accepted Answer

Expressive aphasia makes it difficult for the patient to initiate speech.

Question 11

The nurse explains that the purpose of a stent in the carotid artery of a person with a TIA is to:

Accepted Answer

The only purpose of a stent is to keep an artery open.

Question 12

The nurse takes into consideration that 3% of strokes occur to persons younger than 45 years of age,which are caused by:

Accepted Answer

Strokes in younger people are caused by drug abuse,birth control pills,sickle cell anemia,leukemia,atrial fibrillation,and rheumatic fever.Alcohol abuse and hemophilia do not have a causative role in stroke.

Question 13

The nurse encourages which one of the following posthospital options that would provide the most comprehensive assistance to a patient who is recovering from a CVA?

Accepted Answer

A rehabilitation center with all modalities of support (e.g.,physical therapy,occupational therapy,speech therapy,simulated home environments)is obviously the best option.

Question 14

The nurse explains that a lacunar stroke differs from an ischemic CVA in that a lacunar CVA:

Accepted Answer

The lacunar CVA only affects small arteries and produces a small amount of neurologic damage.

Quiz 28: Cerebrovascular Accident