Deck 28: Cerebrovascular Accident

Question 1

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.The nurse assesses:

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

Answer 1

Stroke in evolution with dysarthria

Question 2

The patient recovering from a CVA asks the purpose of the warfarin (Coumadin).The best response by the nurse is that 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.

Answer 2

Prevents the formation of new clots.

Question 3

A patient has weakness on the right side and impaired reasoning after having a cerebrovascular accident (CVA)in the:

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

Answer 3

Left hemisphere of the cerebrum

Question 4

The nurse assesses that the patient with a CVA is in transition to the rehabilitation phase when:

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 5

The 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 6

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

A) Patient's complaint of nausea
B) Blood pressure (BP) of 140/90 mm Hg
C) Patient's complaint of headache
D) Auscultation of a bruit over the carotid artery

Question 7

Several days after a CVA,the patient's family asks the 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 8

The nurse explains that a patient who has been determined to have had a complete stroke as a result of a ruptured vessel in the left hemisphere would be classified as:

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

Question 9

A patient who has suffered a hemorrhagic stroke is placed on a protocol of 60 mg calcium channel blocker (nimodipine)every 4 hours.The patient's pulse is 82 beats/min before the administration of the prescribed dose.The nurse should:

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).

Question 10

The nurse explains that a lumbar puncture is most helpful as a diagnostic tool for a new patient who has had a CVA because it can help determine if the stroke:

A) Is lacunar
B) Is hemorrhagic or embolic
C) Is complete or in evolution
D) Will result in paralysis

Question 11

Immediately after a CVA,a major nursing priority is ensuring:

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

Question 12

In the rehabilitation phase of a CVA,patients with homonymous hemianopsia need to have their environments arranged so that persons approaching and important items are visible and available on:

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

Question 13

The patient who experienced a TIA is prescribed warfarin (Coumadin)and has laboratory reports reflecting a therapeutic range for that drug that are:

A) Prothrombin time (PT), 35 seconds; control (normal), 20 seconds; international normalized ratio (INR),
B) Partial thromboplastin time (PTT), 30 seconds; control (normal), 30 seconds
C) PT, 45 seconds; control (normal), 20 seconds; INR, d
D) PTT, 52 seconds; control (normal), 30 seconds.

Question 14

Pneumonia is the most frequent cause of death after a stroke.The intervention that would be contraindicated in the acute care of a patient with a hemorrhagic CVA is to:

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

The assessments that indicate a fluid volume excess in a patient in the acute phase of a CVA is:

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

Question 16

The nurse recognizes that the acute phase of a CVA has ended when:

A) 48 hours has passed from its onset.
B) Patient begins to respond verbally.
C) BP drops.
D) Vital signs and neurologic signs stabilize.

Question 17

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

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 18

The nurse adds to the nursing care plan the intervention that will help preserve joint mobility in the acute phase of a CVA,which is:

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 19

The nurse counsels that the patient at the greatest risk for a CVA is a:

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

Question 20

The nurse updates the teaching plan for a patient who suffered a TIA to include the provision for:

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

Question 21

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:

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 22

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

A) Limit fluid intake from 32 to 50 ounces 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 23

The nurse suspects a TIA has occurred when the assessment of a patient reveals transitory: (Select all that apply.)

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

Question 24

The nurse explains that a lacunar stroke differs from an ischemic CVA in that a lacunar 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 large amount of neurologic damage.

Question 25

The nurse assesses patients with CVAs who are candidates for treatment with tPA.They include a: (Select all that apply.)

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

Question 26

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:

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

Question 27

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:

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 28

The nurse explains that the purpose of a stent in the carotid artery of a person with a TIA is to: (Select all that apply.)

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 29

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

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

Question 30

The nurse is supportive of the frustrated patient with expressive aphasia because the condition is characterized by: (Select all that apply.)

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

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

Question 32

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

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

Question 33

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?

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 34

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.