Question 1

The nurse is caring for a client who had a stroke resulting from a ruptured aneurysm and subarachnoid hemorrhage. Which of the following interventions should be included in the care plan?

Accepted Answer

The client with a subarachnoid hemorrhage usually has minimal activity to prevent
cerebral vasospasm or further bleeding and is at risk for venous thrombo-embolism (VTE). Activities such as coughing and sitting up that might increase intracranial pressure (ICP)
or decrease cerebral blood flow are avoided. Because there is no indication that the client is unconscious, an oropharyngeal airway is inappropriate.

Question 2

The health care provider prescribes clopidogrel for a client with cerebral atherosclerosis. Which of the following information should the nurse include when teaching the client about the new medication?

Accepted Answer

Plavix inhibits platelet function as it increases the risk for bleeding, so clients should be advised to notify the health care provider about any signs of bleeding. The medication does not lower blood pressure, decrease plaque formation, or dissolve clots.

Question 3

The nurse is caring for a client who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects. Which of the following actions should the nurse anticipate as treatment for this client?

Accepted Answer

The client's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The client's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA.

Question 4

Several weeks after a stroke, a client has urinary incontinence resulting from an impaired awareness of bladder fullness. For an effective bladder training program, which of the following nursing interventions will be best to include in the plan of care?

Accepted Answer

Developing a regular voiding schedule will prevent incontinence and may increase client awareness of a full bladder. A 1 200 mL fluid restriction may lead to dehydration.
Intermittent catheterization and use of a condom catheter are appropriate in the acute phase of stroke but should not be considered solutions for long-term management because of the risks for urinary tract infection (UTI) and skin breakdown.

Question 5

The nurse is caring for a client with a left-sided brain stroke who suddenly bursts into tears when family members visit. Which of the following actions should the nurse implement?

Accepted Answer

Clients who have left-sided brain stroke are prone to emotional outbursts, which are not necessarily related to the emotional state of the client. Depression after a stroke is common, but the suddenness of the client's outburst suggests that depression is not the major cause of the behaviour. The family should stay with the client. The crying is not within the client's control and asking the client to stop will lead to embarrassment.

Question 6

The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to insufficient dietary intake (secondary to impaired self-feeding ability) for a client with right-sided hemiplegia. Which of the following interventionsshould be included in the plan of care?

Accepted Answer

Because the nursing diagnosis indicates that the client's imbalanced nutrition is related to the right-sided hemiplegia, the appropriate interventions will focus on teaching the client to use the left hand for self-feeding. The other interventions are appropriate for clients with other etiologies for the imbalanced nutrition.

Question 7

The nurse is admitting a client who had a stroke and is experiencing right-sided arm and leg paralysis and facial drooping on the right side. Which of the following clinical manifestations should the nurse expect to find?

Accepted Answer

Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with comprehension and use of language. The left-side reflexes are likely to be intact.
Impulsive behaviour and neglect are more likely with a right-side stroke.

Question 8

The nurse is caring for a client who has had a stroke and has a new prescription to attempt oral feedings. After assessing the client's gag reflex, which of the following actions should the nurse do next?

Accepted Answer

The client should be as upright as possible before attempting feeding to make swallowing easier and decrease aspiration risk. To assess swallowing ability, the nurse should initially offer water or ice to the client. Puréed diets are not recommended because the texture is too smooth. The client may have a poor appetite, but the oral feeding should be attempted regardless.

Question 9

A client who has a history of a transient ischemic attack (TIA) has an order for Aspirin 160 mg daily. When the nurse is administering the medications, the client says, "I don't need the Aspirin today. I don't have any aches or pains." Which of the followingactions should the nurse take?

Accepted Answer

Aspirin is ordered to prevent stroke in clients who have experienced TIAs. Documentation of the client's refusal to take the medication is an inadequate response by the nurse. There is no need to clarify the order with the health care provider. The Aspirin is not ordered to prevent aches and pains.

Question 10

The nurse receives a verbal report that a client has an occlusion of the left posterior cerebral artery. Which of the following findings should the nurse anticipate?

Accepted Answer

Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with middle cerebral artery involvement. Cognitive deficits and changes in judgement are more typical of anterior cerebral artery occlusion.

Question 11

The nurse is admitting a client with left-sided homonymous hemianopsia resulting from a stroke. Which of the following interventions should the nurse include in the plan of care during the acute period of the stroke?

Accepted Answer

During the acute period, the nurse should place objects on the client's unaffected side. Since there is a visual defect in the left half of each eye, an eye patch is not appropriate. The client should be approached from the right side. The visual deficit may not resolve, although the client can learn to compensate for the defect.

Question 12

The nurse is caring for a client who had a stroke affecting the right hemisphere of the brain. Which of the following nursing diagnoses is appropriate based on knowledge of the effects of right brain damage?

Accepted Answer

Right-sided brain damage typically causes denial of any deficits and poor impulse control, leading to risk for injury when the client attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability.

Question 13

The nurse is assessing a client with a possible stroke and finds that the client's aphasia started 3.5 hours previously and the blood pressure is 170/92 mm Hg. Which of these prescriptions by the health care provider should the nurse question?

Accepted Answer

Because elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if mean arterial pressure (MAP) is >130 mm Hg or systolic pressure is >220 mm Hg. Fluid intake should be 1 500-2 000 mL daily to maintain cerebral blood flow. The head of the bed should be elevated to at least 30 degrees, unless the client has symptoms of poor tissue perfusion. tPA may be administered if the client meets the other criteria for tPA use.

Question 14

The nurse obtains all of the following information about a client in the clinic. When developing a plan to decrease stroke risk, which of the following risk factors is most important for the nurse to address?

Accepted Answer

Hypertension is the single most important modifiable risk factor and this client's hypertension is at the stage 2 level. People who drink more than 1 (for women) or 2 (for men) alcoholic beverages a day may increase risk for hypertension. Physical inactivity and obesity contribute to stroke risk but not so much as hypertension.

Question 15

The nurse is caring for a client who has right-sided weakness after a stroke and is attempting to use the left hand for feeding and other activities. The client's partner insists on feeding and dressing him, telling the nurse, "I just don't like to seehimstruggle." Which of the following nursing diagnoses is most appropriate for the client?

Accepted Answer

The information supports the diagnosis of disabled family coping because the client's partner does not understand the rehabilitation program. There are no data supporting low self-esteem, and the client is attempting independence. The data do not support an interruption in family processes because this may be a typical pattern for the couple. There is no indication that the client has impaired nutrition.

Question 16

The health care provider recommends a carotid endarterectomy for a client with carotid atherosclerosis and a history of transient ischemic attacks (TIAs). The client asks the nurse to describe the procedure. Which of the following responses by the nurseisappropriate?

Accepted Answer

In a carotid endarterectomy, the carotid artery is incised and the plaque is removed. The response beginning, "The diseased portion of the artery in the brain is removed" describes an arterial graft procedure. The answer beginning, "A catheter with a deflated balloon is positioned at the narrow area" describes an angioplasty. The final response beginning, "A wire is threaded through the artery" describes the MERCI procedure.

Question 17

The nurse identifies the nursing diagnosis of impaired verbal communication for a client with expressive aphasia. Which of the following actions should the nurse implement to help the client communicate?

Accepted Answer

Communication will be facilitated and less frustrating to the client when questions that require a "yes" or "no" response are used. When the language areas of the brain are injured, the client might not be able to read or recite words, which will frustrate the client without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the client to respond.

Question 18

A client is admitted to the hospital with dysphasia and right-sided weakness that resolves in a few hours. The nurse will anticipate teaching the client about

Accepted Answer

Following a TIA, clients typically are started on medications such as Aspirin to inhibit platelet function and decrease stroke risk. tPA is used for acute ischemic stroke. Warfarin is usually used for clients with atrial fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage.

Question 19

Aclient with a history of several transient ischemic attacks (TIAs) arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. Which of the following procedures should the nurse anticipate?

Accepted Answer

The client's history and clinical manifestations suggest an acute ischemic stroke and a client who is seen within 3-4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy is not indicated for the client who is having an acute ischemic stroke.

Question 20

The nurse is caring for a client who has recently had a stroke. When reviewing the clients' laboratory report, which of the following results should the nurse report the health care provider?

Accepted Answer

All of the lab values are within normal range except for the PaCO₂. A high PaCO₂ is a potent vasodilator that increases cerebral blood flow.

Quiz 60: Nursing Management Stroke