Question 1

A patient comes into the emergency department with symptoms of a stroke.Which medication should the nurse expect may be given to the patient if diagnostic testing confirms an ischemic stroke?

Accepted Answer

tPA is a thrombolytic agent that can break down the thrombus causing the occlusion,which can potentially prevent or completely reverse the symptoms of an ischemic stroke.A.B.C.Heparin,warfarin,and clopidogrel can help prevent clots but are not effective in breaking up an existing clot.

Question 2

The patient is diagnosed with a cerebral vascular accident that has the slowest rate of recovery and the highest probability of causing extensive neurological deficits.For which type of stroke should the nurse plan care for this patient?

Accepted Answer

SAH is caused by rupture of blood vessels on the surface of the brain.This type of infarct has the slowest rate of recovery and the highest probability of leaving the patient with extensive neurological deficits.B.Aneurysms are often asymptomatic if they do not bleed.D.RIND is reversible.A.A thrombotic stroke does not have the slowest rate of recovery.

Question 3

A patient with a temporary loss of motor function is diagnosed with a transient ischemic attack (TIA).What should the nurse include when assisting in the teaching about this health problem?

Accepted Answer

TIA is a temporary impairment of the cerebral circulation causing neurological impairment that lasts less than 24 hours.A.A hemorrhage would cause a hemorrhagic stroke.D.A fully occluded vessel causes an ischemic stroke.C.Tangled messages refer to Alzheimer's disease.

Question 4

The nurse is assisting with teaching a patient who has had a transient ischemic attack (TIA).On which understanding should the nurse base teaching?

Accepted Answer

About a third of patients who experience a TIA will have a stroke in the future.A.Urgent evaluation of TIA is essential in order to decrease the risk of stroke.B.There are no data related to myocardial infarction (MI)prediction.C.It is not a surgical problem.

Question 5

The nurse is assisting in preparing a patient for transfer to a rehabilitation facility after a stroke.What should the nurse explain as the goal for rehabilitation?

Accepted Answer

Rehabilitation can help the patient maximize remaining abilities.A.D.At this point,the patient's neurological status should be stable,and all the diagnostic work has been completed.B.Cure is not realistic.

Question 6

A client with a subarachnoid bleed refuses to use a bedpan and becomes angry when denied permission to walk to the bathroom.While waiting to hear from the health care provider (HCP),which action should the nurse take?

Accepted Answer

Patients with subarachnoid hemorrhage are at risk for rebleeding.A.Straining to have a bowel movement and agitation both increase the risk of rebleeding.B.The patient may need to be sedated until the physician can be contacted.C.Bringing in security will be upsetting to the patient and can also increase the risk of raising the BP and bleeding.

Question 7

The nurse is documenting care provided to a patient with left-sided flaccidity caused by a stroke.Which term should the nurse use to document this patient's motor status?

Accepted Answer

A patient with a stroke has symptoms on the opposite side of the stroke,which is called contralateral.One-sided flaccidity is called hemiplegia.A.Ipsilateral means the same side.Para refers to the lower extremities.D.Quad refers to all four extremities; B.Hemiparesis is another term for hemiplegia.

Question 8

The nurse is planning care for a client with right-sided weakness and aphasia from a transient ischemic attack (TIA).Which area of the brain should the nurse realize was affected in this client?

Accepted Answer

Symptom onset is sudden and generally involves one side of the body-the side of the body opposite to the damaged area.A.B.The manifestations of right-sided weakness and aphasia would not be present if the TIA occurred in the medulla or occipital lobe.D.The client would have left-sided manifestations if the TIA occurred in the right hemisphere.

Question 9

A patient tells the nurse that at times it seems like the mouth muscles do not want to work and the patient's speech is slurred.What should the nurse realize that the patient is describing?

Accepted Answer

Slurred or indistinct speech because of a motor problem or lack of coordination is referred to as dysarthria.A.Diplopia is double vision.C.Dysphasia refers to difficulty swallowing.D.Dysrhythmia is an irregular heartbeat.

Question 10

A patient is diagnosed with a stroke that occurred at 12 noon the previous day.When should the nurse plan to begin bedside physical therapy with this patient?

Accepted Answer

Patients should be mobilized within 24 hours if possible to prevent complications of immobility.Physical and occupational therapy are provided to maximize functioning and to progress the patient toward a return to baseline functioning.A.B.D.Waiting to begin physical therapy could reduce the patient's success with physical rehabilitation.

Question 11

The nurse is reviewing teaching provided to a patient with transient ischemic attack (TIA).Which statement indicates that further teaching is required?"

Accepted Answer

There is no association between TIA and the development of Alzheimer's disease.A.The risk factors,causes,and symptoms of a TIA are identical to a cerebrovascular accident (CVA).Patients who have had a TIA have an increased risk of having a stroke.Treatment,therefore,is mostly focused on minimizing the patient's risk factors for a stroke.B.D.Modifiable risk factors are those risks that can be changed by treatment,such as treating high blood pressure,or by lifestyle modification,such as stopping smoking.

Question 12

The nurse is caring for a hospitalized patient who has had a stroke and is waiting to be transferred to a rehabilitation facility.What nursing action can best maximize the patient's rehabilitation potential while awaiting the transfer?

Accepted Answer

Rehabilitation should begin as soon as the patient is stable.Waiting until the patient is at the rehabilitation facility to begin therapy wastes valuable time.A.Teaching the patient what to expect at the rehabilitation facility will not maximize the patient's rehabilitation potential.B.Keeping the patient on bedrest could cause further mobility issues.D.Turning the patient every 2 hours to prevent ulcer formation and contractures will not necessarily maximize the patient's rehabilitation potential.

Question 13

The nurse is planning care for a patient with an intracerebral hemorrhage.What should be identified as a goal for this patient?

Accepted Answer

An intracerebral hemorrhage is usually caused by uncontrolled hypertension.Maintaining blood pressure below 120/80 mm Hg should be the goal for these patients.B.These patient cannot resume activities of daily living until the bleeding is controlled within the brain.C.Transient numbness and tingling could indicate additional brain damage from bleeding.D.Thrombolytic therapy is not indicated for an intracerebral hemorrhage.

Question 14

A patient is admitted to the hospital with a severe headache and photophobia.A lumbar puncture confirms a bleeding aneurysm.What nursing interventions should the nurse anticipate assisting with to prevent increased intracranial pressure (ICP)during the acute phase of illness?

Accepted Answer

A quiet room with minimal stressors,elevated head,and stool softeners can help reduce ICP.A.C.Morphine and tranquilizers are not usually recommended because they can make neurological assessment difficult.A.C.Expectorants can promote coughing,which can raise ICP.C.D.Exercises,moving,and suctioning can also raise ICP.

Question 15

A patient enters the emergency department with right-sided weakness and vision changes.What assessment finding should be communicated to the registered nurse (RN)or HCP immediately?

Accepted Answer

All the data are significant.However,the onset of symptoms is within the time frame for the patient to receive a thrombolytic.If the nurse acts quickly,the patient's stroke may be able to be reversed.

Question 16

A patient is prescribed an antiplatelet agent to prevent strokes.Which agent was this patient most likely prescribed?

Accepted Answer

Aspirin is a platelet aggregation inhibitor.C.Tylenol is an analgesic but does not affect platelet function.B.Warfarin is an anticoagulant.D.tPA is a thrombolytic agent.

Question 17

A patient with symptoms of impending stroke is scheduled to have a cerebral angiogram.Which statement should the nurse include when assisting with patient teaching?

Accepted Answer

A cerebral angiogram may be completed to determine the patency of cerebral vessels and the status of any collateral circulation.D.A lumbar puncture is done to examine cerebrospinal fluid (CSF).B.Edema may be identified by radiography.C.An electroencephalogram (EEG)shows electrical function.

Question 18

A patient began experiencing manifestations of a stroke at 0800 hours.By which time should thrombolytic medications be provided to reverse stroke symptoms?

Accepted Answer

If a patient experiencing ischemic stroke symptoms receives treatment within 4.5 hours of symptom onset,medication can be provided to resolve the deficits.A.A patient needs to be treated within 4.5 hours and not 1 hour.C.D.This is too long to wait to provide medication to treat the symptoms of a stroke.

Question 19

A patient with a cerebrovascular accident (stroke)has left-sided flaccidity and is unable to speak but seems to understand everything the nurse says.Which term should the nurse use to document the patient's communication impairment?

Accepted Answer

Aphasia may be expressive,in which the patient knows what he or she wants to say but cannot speak or make sense.D.Receptive aphasia is an inability to understand spoken or written words.The patient experiencing receptive aphasia is unable to understand language.B.Dysphagia refers to difficulty swallowing.A.Sensory aphasia is not a type of communication impairment.

Question 20

A patient is experiencing bilateral hemiparesis,dysphasia,visual changes,and altered level of consciousness,ataxia,and dysphagia.Which artery was most likely affected in this patient's stroke?

Accepted Answer

These are symptoms of vertebrobasilar/cerebellar occlusion.A.B.C.Carotid and middle or posterior cerebral occlusions are not associated with ataxia or dysphagia.

Quiz 49: Nursing Care of Patients With Cerebrovascular Disorders

A patient comes into the emergency department with symptoms of a stroke.Which medication should the nurse expect may be given to the patient if diagnostic testing confirms an ischemic stroke?

The patient is diagnosed with a cerebral vascular accident that has the slowest rate of recovery and the highest probability of causing extensive neurological deficits.For which type of stroke should the nurse plan care for this patient?

A patient with a temporary loss of motor function is diagnosed with a transient ischemic attack (TIA) .What should the nurse include when assisting in the teaching about this health problem?

The nurse is assisting with teaching a patient who has had a transient ischemic attack (TIA) .On which understanding should the nurse base teaching?

The nurse is assisting in preparing a patient for transfer to a rehabilitation facility after a stroke.What should the nurse explain as the goal for rehabilitation?

A client with a subarachnoid bleed refuses to use a bedpan and becomes angry when denied permission to walk to the bathroom.While waiting to hear from the health care provider (HCP) ,which action should the nurse take?

The nurse is documenting care provided to a patient with left-sided flaccidity caused by a stroke.Which term should the nurse use to document this patient's motor status?

The nurse is planning care for a client with right-sided weakness and aphasia from a transient ischemic attack (TIA) .Which area of the brain should the nurse realize was affected in this client?

A patient tells the nurse that at times it seems like the mouth muscles do not want to work and the patient's speech is slurred.What should the nurse realize that the patient is describing?

A patient is diagnosed with a stroke that occurred at 12 noon the previous day.When should the nurse plan to begin bedside physical therapy with this patient?

The nurse is reviewing teaching provided to a patient with transient ischemic attack (TIA) .Which statement indicates that further teaching is required?"

The nurse is caring for a hospitalized patient who has had a stroke and is waiting to be transferred to a rehabilitation facility.What nursing action can best maximize the patient's rehabilitation potential while awaiting the transfer?

The nurse is planning care for a patient with an intracerebral hemorrhage.What should be identified as a goal for this patient?

A patient is admitted to the hospital with a severe headache and photophobia.A lumbar puncture confirms a bleeding aneurysm.What nursing interventions should the nurse anticipate assisting with to prevent increased intracranial pressure (ICP) during the acute phase of illness?

A patient enters the emergency department with right-sided weakness and vision changes.What assessment finding should be communicated to the registered nurse (RN) or HCP immediately?

A patient is prescribed an antiplatelet agent to prevent strokes.Which agent was this patient most likely prescribed?

A patient with symptoms of impending stroke is scheduled to have a cerebral angiogram.Which statement should the nurse include when assisting with patient teaching?

A patient began experiencing manifestations of a stroke at 0800 hours.By which time should thrombolytic medications be provided to reverse stroke symptoms?

A patient with a cerebrovascular accident (stroke) has left-sided flaccidity and is unable to speak but seems to understand everything the nurse says.Which term should the nurse use to document the patient's communication impairment?

A patient is experiencing bilateral hemiparesis,dysphasia,visual changes,and altered level of consciousness,ataxia,and dysphagia.Which artery was most likely affected in this patient's stroke?