Deck 22: Caring for the Patient With Cerebral Vascular Disorders

Question 1

The nurse is caring for a patient who is being treated for cerebral vasospasm with a medical treatment known as triple-H therapy. Which assessment data confirm that the treatment is currently effective? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) Mean arterial pressure MAP) 110 mmHg
B) Hematocrit 34%
C) Sodium of 125 mg/dL
D) Urine output 40 ml/hr
E) BP 170/96

Answer 1

Mean arterial pressure MAP) 110 mmHg
Hematocrit 34%
Sodium of 125 mg/dL
BP 170/96

Question 2

The nurse is caring for a patient who experienced an ischemic stroke 8 hours ago. The nurse would expect an order to administer which medications designed to prevent further obstruction of vascular cerebral blood flow? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) Intravenous dopamine
B) Intravenous mannitol
C) Subcutaneous insulin
D) Intravenous heparin
E) Subcutaneous low-molecular-weight heparin

Answer 2

Intravenous heparin
Subcutaneous low-molecular-weight heparin

Question 3

Which assessment data alerts the nurse to the fact that the patient is at risk for an embolic stroke?

A) Blood sugar of 110 mg
B) Right partial lung lobectomy 6 months ago
C) BP 108/68
D) History of atrial fibrillation

Answer 3

History of atrial fibrillation

Question 4

An emergency department nurse is caring for a patient who has been diagnosed with an evolving ischemic stroke. The nurse anticipates preparing the patient and family for which initial medical intervention?

A) Craniotomy
B) Administration of t-PA tissue plasminogen activator)
C) Full-body X-ray series
D) Watchful waiting over the next 24 hours

Question 5

The nurse is discussing stroke etiology with a community group. The nurse would describe which mechanism as causing the most common kind of stroke?

A) Ischemia
B) Hemorrhage
C) Headache
D) Spasm

Question 6

A patient has undergone repair of a subarachnoid hemorrhage. The nurse should monitor this patient for development of which complications? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) Hypernatremia
B) Hydrocephalus
C) Rebleeding
D) Vasospasm
E) Hemodilution

Question 7

A patient has been hospitalized for scheduled repair of an intracranial aneurysm. The nurse caring for the patient prior to surgery would recognize which manifestations as indicating the aneurysm may be leaking or may have ruptured? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) Visual deficits
B) Headache
C) Mild nausea
D) Dilated pupil
E) Stiff neck

Question 8

A patient is being treated for an aneurysmal subarachnoid hemorrhage SAH) that occurred 10 days ago. The nurse recognizes that the patient is at risk for decreased cerebral blood flow and is especially concerned when which assessments are made? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) The patient seems unable to verbalize needs.
B) The patient has difficulty starting the flow of urine.
C) The patient reports a stiff neck.
D) The patient has a temperature of 101°F.
E) The patient has unequal but reactive pupils.

Question 9

A hospitalized patient has become unresponsive. The left side of the body is flaccid. The attending physician believes the patient may have had a hemorrhagic stroke. What is the nurse's priority intervention?

A) Move the patient to the critical care unit.
B) Assess blood pressure.
C) Assess the airway and breathing.
D) Observe urinary output.

Question 10

After being informed that their father has experienced a stroke that has affected a portion of his cerebrum, the patient's family asks the nurse, "What effect will aphasia have on his life?" How should the nurse respond?

A) "He will likely become depressed until he adjusts to the dysfunction."
B) "You'll have to speak very loudly when you talk."
C) "The way he communicates with you will change."
D) "Perhaps you should learn about the different options for speech therapy."

Question 11

A post-stroke patient is going home on oral Coumadin warfarin). During discharge teaching, which statement by the patient reflects an understanding of the effects of this medication?

A) "I will stop taking this medicine if I notice any bruising."
B) "I will not eat spinach while I'm taking this medicine."
C) "It will be OK for me to eat anything."
D) "I'll check my blood pressure frequently while taking this medication."

Question 12

A diagnosis of cerebral salt wasting is made for a patient who recently experienced a subarachnoid hemorrhage SAH) and is hyponatremic. The nurse recognizes the importance of which interventions? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) Strictly monitoring intake and output
B) Monitoring hypertonic IV fluid therapy
C) Securing a serum sodium level every 6 hours
D) Restricting the patient's fluids to 200 mL daily
E) Administering oral salt supplements

Question 13

A 27-year-old male arrives at the emergency department reporting a sudden severe-onset headache. Diagnostic studies confirm he is experiencing an intracerebral hemorrhage. The nurse recognizes which risk factor for this condition in the patient's history?

A) The patient reports having a sprained ankle last week, for which he took ibuprofen.
B) The patient reports smoking a pack of cigarettes a day since he was 16 years old.
C) The patient is 27 years old.
D) The patient is male.

Question 14

A patient is admitted with signs of a stroke CVA). On admission, vital signs were blood pressure 128/70, pulse 68, and respirations 20. Two hours later the patient is not awake, has a blood pressure of 170/70, pulse 52, and the left pupil is now slower than the right pupil in reacting to light. These findings suggest which condition?

A) Impending brain death
B) Decreasing intracranial pressure
C) Stabilization of the patient's condition
D) Increasing intracranial pressure

Question 15

The nurse is preparing an educational program focusing on various types of strokes. What types of strokes would the nurse include in a discussion of ischemic strokes? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) Cardioembolic
B) Intracerebral hemorrhagic
C) Lacunar
D) Subarachnoid hemorrhagic
E) Atherosclerotic thrombotic

Question 16

The nurse is teaching a wellness class and is discussing the warning signs of stroke. A patient asks, "What is the most important thing for me to remember?" Which is an appropriate response by the nurse?

A) "Know your family history."
B) "Keep a list of your medications."
C) "Be alert for sudden weakness or numbness."
D) "Call 911 if you notice a gradual onset of paralysis or confusion."

Question 17

A patient's initial assessment revealed blood pressure 128/70, pulse 68, respirations 20, and pupils equal and reactive. The patient is awake and responding to verbal stimuli but demonstrating weakness on the left side. A medical diagnosis is presumptive stroke. Two hours later the patient is not awake but is easily aroused, has a blood pressure of 140/70, pulse 52, respirations 18, and the left pupil now reacts more slowly to light than the right pupil. Which complication is likely to have occurred?

A) Reperfusion injury
B) Normal stabilization poststroke
C) Increased intracranial pressure
D) Impending brain death

Question 18

The nurse is caring for a patient who is at risk for developing cerebral vasospasm. The nurse recognizes which order as inappropriate for this patient?

A) Discontinue IV fluids when tolerating fluids.
B) Monitor serum electrolytes daily.
C) Hold antihypertensive medications.
D) Monitor blood pressure hourly.

Question 19

A patient has infarct of the right anterior cerebral artery. The nurse would attribute which assessment findings to this condition? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) The patient is incontinent of urine.
B) The patient cannot move the right leg.
C) The patient does not respond to light touch on the feet.
D) The patient cannot speak.
E) The patient has paralysis of the right arm.

Question 20

The nurse is reinforcing education regarding the risks of bypass procedures for a patient who has had an ischemic stroke. What risks should the nurse discuss? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) Infection
B) Unstable blood pressure
C) Renal failure
D) Thrombotic stroke
E) Hemorrhage

Question 21

A patient will have either endovascular coiling or neurosurgical clipping as treatment for an intracranial aneurysm. How would the nurse describe the benefits and risks of each form of treatment? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) Surgery is the most reliable method of treating these aneurysms.
B) Coiling is only successful in very small aneurysms.
C) The decision of which approach to use is based on the patient's preference.
D) Coiling is generally a less invasive option.
E) Coiling may require placement of a stent.

Question 22

Diagnostic testing has revealed that the patient has an arteriovenous malformation AVM). Surgical treatment is scheduled for tomorrow. Which critical assessment findings should the nurse report to the surgeon? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) Headache unchanged since admission
B) Seizure
C) A period of sudden clarity after previously disturbed thought processing
D) Increased difficulty in talking
E) Sudden decrease in level of consciousness

Question 23

A patient is admitted to the emergency department after complaining of a headache and having a seizure. On CT examination the patient is assigned a Fisher score of 1. How does the nurse evaluate this information?

A) There is no blood detected on the CT scan.
B) The CT scan shows no ischemia.
C) The CT scan must be repeated with contrast.
D) The aneurysm can be treated with coiling.

Question 24

A patient with a family history of cavernous malformation presents to the emergency department following a seizure. The nurse anticipates which diagnostic testing?

A) Angiography
B) CT scan
C) Skull series X-ray
D) MRI scan

Question 25

A patient experienced onset of weakness, left-sided facial drooping, and difficulty talking 2 hours before presenting in the emergency department. The patient has been in the ED for 30 minutes, and the nurse is aware that t-PA treatment for stroke must be administered within the next _______ hours to be effective.

Question 26

Results of diagnostic procedures reveal that a patient's cerebral arteriovenous malformation AVM) is Spetzler-Martin grade
1) Surgical resection
1) The nurse anticipates which most common treatment for this patient?
2) Endovascular coiling
3) Radiosurgery
4) Watchful waiting

Question 27

The nurse is monitoring a patient who has had a subarachnoid bleed. The nurse plans care based on the knowledge that the risk for cerebral vasospasm is highest in Fisher grade _______ aneurysms.

Question 28

The nurse is presenting a community health program regarding stroke. The nurse emphasizes the importance of early transport to the emergency department. What is the primary rationale for this recommendation?

A) Prompt treatment can save cells in the penumbra.
B) Early reperfusion expands the penumbra.
C) Early intervention can decrease autoregulation.
D) Early treatment eliminates the possibility of reperfusion injury.

Question 29

A patient is diagnosed with a lacunar stroke. The patient's daughter says, "If this is a stroke in a small artery, why is my dad's movement so affected?" Which nursing response is indicated?

A) "Lacunar strokes occur in large arteries, not small ones."
B) "Lacunar strokes look small on the scans, but they often happen in areas where lots of motor and sensory tracts are located."
C) "Most of the time with lacunar strokes, we see more sensory effects than those your dad has experienced."
D) "Lacunar strokes occur in small arteries, but the damage seen on scans is massive."

Question 30

After a stroke, a patient was left with painful feet and hands. The physician diagnoses central pain syndrome. Which home management technique should the nurse teach this patient?

A) "Keep your feet and hands warm."
B) "Walking will improve your comfort."
C) "Taking an ACE inhibitor will decrease the pain."
D) "Ice massage may help your pain."

Question 31

A patient is scheduled for a lumbar puncture to assess for subarachnoid hemorrhage. The nurse should check to see if which test has been performed prior to the procedure?

A) Serum glucose
B) BUN
C) Chest X-ray
D) CT scan of the head

Question 32

A patient has been admitted with stroke-like symptoms. The nurse would report a serum potassium level of less than _____mEq/L as below the desired level.

Question 33

The nurse is planning care for a patient undergoing diagnostic evaluation for presence of an intracranial bleed. Which nursing diagnosis NDX) would the nurse set as the first priority?

A) Impaired Verbal Communication
B) Potential for Aspiration
C) Risk for Altered Cerebral Tissue Perfusion
D) Altered Coping

Question 34

A patient has had successful treatment for a leaking arteriovenous malformation and is being discharged to home. The patient's Barthel Index score is 48. The nurse anticipates that the patient will require which assistance?

A) Partial assistance with daily care activities
B) Maximum assistance with self-care in all activities
C) Very little assistance with activities of daily living
D) No assistance with most activities

Question 35

The patient with assessment findings of stroke has a normal CT scan upon admission to the emergency department. How should the nurse evaluate this information?

A) Intracranial aneurysm is a more likely diagnosis.
B) The patient must have a psychosomatic illness.
C) A second CT done later may show damage.
D) The patient should have an electroencephalogram.