Deck 58: Nursing Management: Stroke

Question 1

A patient with a stroke experiences right-sided arm and leg paralysis and facial drooping on the right side. When obtaining admission assessment data about the patient's clinical manifestations, it is most important the nurse assess the patient's

A) ability to follow commands.
B) visual fields.
C) right-sided reflexes.
D) emotional state.

Answer 1

ability to follow commands.

Question 2

A patient who has had a stroke has a new order to attempt oral feedings. The nurse should assess the gag reflex and then

A) offer the patient a sip of juice.
B) order a varied pureed diet.
C) assess the patient's appetite.
D) assist the patient into a chair.

Answer 2

assist the patient into a chair.

Question 3

A 32-year-old patient has a stroke resulting from a ruptured aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan?

A) Encouraging patient to cough and deep breath every 4 hours
B) Inserting an oropharyngeal airway to prevent airway obstruction
C) Assisting to dangle on edge of bed and assess for dizziness
D) Applying intermittent pneumatic compression stockings

Answer 3

Applying intermittent pneumatic compression stockings

Question 4

A patient with homonymous hemianopsia resulting from a stroke has a nursing diagnosis of disturbed sensory perception related to hemianopsia. To help the patient learn to compensate for the deficit during the rehabilitation period, the nurse should

A) apply an eye patch to the affected eye.
B) approach the patient on the unaffected side.
C) place objects necessary for activities of daily living on the patient's affected side.
D) have the patient use the eye muscles to move the eyes through the entire visual field.

Question 5

The nurse expects that management of the patient who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects will include

A) heparin via continuous intravenous infusion.
B) prophylactic clipping of cerebral aneurysms.
C) therapy with tissue plasminogen activator (tPA).
D) oral administration of ticlopidine (Ticlid).

Question 6

The nurse identifies the nursing diagnosis of impaired verbal communication for a patient with expressive aphasia. An appropriate nursing intervention to help the patient communicate is to

A) ask simple questions that the patient can answer with "yes" or "no."
B) develop a list of words that the patient can read and practice reciting.
C) have the patient practice facial and tongue exercises to improve motor control necessary for speech.
D) prevent embarrassing the patient by changing the subject if the patient does not respond in a timely manner.

Question 7

A patient has right-sided weakness and aphasia as a result of a stroke but is attempting to use the left hand for feeding and other activities. The patient's wife insists on feeding and dressing him, telling the nurse, "I just don't like to see him struggle." A nursing diagnosis that is most appropriate in this situation is

A) situational low self-esteem related to increasing dependence on others.
B) interrupted family processes related to effects of illness of a family member.
C) disabled family coping related to inadequate understanding by patient's spouse.
D) ineffective therapeutic regimen management related to hemiplegia and aphasia.

Question 8

A patient with right-sided weakness that started 1 hour ago is admitted to the emergency department and all these diagnostic tests are ordered. Which order should the nurse act on first?

A) Noncontrast computed tomography (CT) scan
B) Chest radiograph
C) Complete blood count (CBC)
D) Electrocardiogram (ECG)

Question 9

The nurse on the medical unit receives a verbal report from the emergency department nurse that a patient has an occlusion of the left posterior cerebral artery. When admitting the patient to the medical floor, the nurse will anticipate that the patient may have

A) visual deficits.
B) dysphasia.
C) confusion.
D) poor judgment.

Question 10

The health care provider prescribes clopidogrel (Plavix) for a patient with cerebral atherosclerosis. When teaching about the new medication, the nurse will tell the patient

A) that Plavix will reduce cerebral artery plaque formation.
B) to monitor and record the blood pressure daily.
C) to call the health care provider if stools are tarry.
D) that Plavix will dissolve clots in the cerebral arteries.

Question 11

On initial assessment of a patient hospitalized following a stroke, the nurse finds the patient's blood pressure to be 180/90 mm Hg. Which of the following orders by the health care provider should the nurse question?

A) Infuse normal saline at 75 ml/hr.
B) Keep head of bed elevated at least 30 degrees.
C) Administer tissue plasminogen activator (tPA) per protocol.
D) Titrate labetolol (Normodyne) drip to keep BP less than 140/90 mm Hg.

Question 12

Aspirin is ordered for a patient who is admitted with a possible stroke. Which information obtained during the admission assessment indicates that the nurse should consult with the health care provider before giving the aspirin?

A) The patient has atrial fibrillation.
B) The patient has dysphasia.
C) The patient states, "I suddenly developed a terrible headache."
D) The patient has a history of brief episodes of right hemiplegia.

Question 13

A patient with a stroke has progressive development of neurologic deficits with increasing weakness and decreased level of consciousness (LOC). The priority nursing diagnosis for the patient is

A) risk for impaired skin integrity related to immobility.
B) disturbed sensory perception related to brain injury.
C) risk for aspiration related to inability to protect airway.
D) impaired physical mobility related to weakness.

Question 14

The health care provider recommends a carotid endarterectomy for a patient with carotid atherosclerosis and a history of transient ischemic attacks (TIA). The patient asks the nurse to describe the procedure. Which response by the nurse is appropriate?

A) "The diseased portion of the artery in the brain is removed and replaced with a synthetic graft."
B) "The carotid endarterectomy involves surgical removal of plaque from an artery in the neck."
C) "A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque."
D) "A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed."

Question 15

A patient has a stroke affecting the right hemisphere of the brain. Based on knowledge of the effects of right brain damage, the nurse establishes a nursing diagnosis of

A) impaired physical mobility related to right hemiplegia.
B) impaired verbal communication related to speech-language deficits.
C) risk for injury related to denial of deficits and impulsiveness.
D) ineffective coping related to depression and distress about disability.

Question 16

A patient who has had a subarachnoid hemorrhage is being cared for in the intensive care unit. Which information about the patient is most important to communicate to the health care provider?

A) The patient complains of an ongoing severe headache.
B) The patient's blood pressure is 90/50 mm Hg.
C) The cerebrospinal fluid (CFS) report shows red blood cells (RBCs).
D) The patient complains about having a stiff neck.

Question 17

The nurse obtains all of the following information about a 65-year-old patient in the clinic. When developing a plan to decrease stroke risk, which risk factor is most important for the nurse to address?

A) The patient smokes a pack of cigarettes daily.
B) The patient's blood pressure (BP) is chronically between 150/80 to 170/90 mm Hg.
C) The patient works at a desk and relaxes by watching television.
D) The patient is 25 pounds above the ideal weight.

Question 18

The nurse is assisting the patient who is recovering from an acute stroke and has right-side hemiplegia to transfer from the bed to the wheelchair. Which action by the nurse is appropriate?

A) Positioning the wheelchair next to the bed on the patient's right side
B) Placing the wheelchair parallel to the bed on the patient's left side
C) Setting the wheelchair directly in front of the patient, who is sitting on the side of the bed
D) Moving the wheelchair a few steps from the bed and having the patient walk to the chair

Question 19

A patient with a history of several transient ischemic attacks (TIAs) arrives in the emergency room with hemiparesis and dysarthria that started 2 hours previously. The nurse anticipates the need to prepare the patient for

A) intravenous heparin administration.
B) transluminal angioplasty.
C) surgical endarterectomy.
D) tissue plasminogen activator (tPA) infusion.

Question 20

The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to inability to feed self for a patient with right-sided hemiplegia. An appropriate nursing intervention is to

A) assist the patient to eat with the left hand.
B) provide oral care before and after meals.
C) teach the patient the "chin-tuck" technique.
D) provide a wide variety of food choices.

Question 21

A 72-year-old is being discharged home following a stroke. The patient is able to walk with assistance but needs help with hygiene, dressing, and eating. Which statement by the patient's wife indicates that discharge planning goals have been met?

A) "I can provide the care my husband needs if I use the support and resources available in the community."
B) "Because my husband will have continuous improvement in his condition, I won't need outside assistance in his care for very long."
C) "I can handle all of my husband's needs thanks to the instructions you've given me."
D) "I have arranged for a home health aide to provide all the care my husband will need."

Question 22

A patient with a left-sided brain stroke suddenly bursts into tears when family members visit. The nurse should

A) explain to the family that depression is normal following a stroke.
B) have the family members leave the patient alone for a few minutes.
C) teach the family that emotional outbursts are common after strokes.
D) use a calm voice to ask the patient to stop the crying behavior.

Question 23

A patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first?

A) Obtain the Glasgow Coma Scale score.
B) Check the respiratory rate.
C) Monitor the blood pressure.
D) Send the patient for a CT scan.

Question 24

A patient with sudden-onset right-sided weakness has a CT scan and is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider?

A) The patient has atrial fibrillation and takes warfarin (Coumadin).
B) The patient takes a diuretic because of a history of hypertension.
C) The patient's blood pressure is 144/90 mm Hg.
D) The patient's speech is difficult to understand.

Question 25

Several weeks after a stroke, a patient has urinary incontinence resulting from an impaired awareness of bladder fullness. A bladder retraining program for the patient should include

A) limiting fluid intake to 1000 ml daily to reduce urine volume.
B) assisting the patient onto the bedside commode every 2 hours.
C) performing intermittent catheterization after each voiding to check for residual urine.
D) using an external "condom" catheter to protect the skin and prevent embarrassment.

Question 26

The nurse is caring for a patient with carotid artery narrowing who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse?

A) The pulse rate is 104 beats/min.
B) There are fine crackles at the lung bases.
C) The patient has difficulty talking.
D) The blood pressure is 142/88 mm Hg.

Question 27

A patient 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 patient says, "I don't need the aspirin today. I don't have any aches or pains." Which action should the nurse take?

A) Document that the aspirin was refused by the patient.
B) Call the health care provider to clarify the medication order.
C) Explain that the aspirin is ordered to decrease stroke risk.
D) Tell the patient that the aspirin is used to prevent aches.

Question 28

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

A) alteplase (tPA).
B) aspirin (Ecotrin).
C) warfarin (Coumadin).
D) nimodipine (Nimotop).