Deck 60: Nursing Management: Stroke

Question 1

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 the patient to cough and breathe deeply every 4 hours
B) Inserting an oropharyngeal airway to prevent airway obstruction
C) Assisting the patient to dangle on the edge of the bed and assessing for dizziness
D) Applying intermittent pneumatic compression stockings

Answer 1

Applying intermittent pneumatic compression stockings

Question 2

When initiating oral feedings for a patient with a stroke,the nurse determines that the patient has an intact gag reflex and then does which of the following actions?

A) Offers the patient a sip of juice
B) Orders a varied puréed diet
C) Assesses the patient's appetite
D) Assists the patient into a chair

Answer 2

Assists the patient into a chair

Question 3

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 is chronically between 150/80 and 170/90 mm Hg.
C) The patient works at a desk and relaxes by watching television.
D) The patient is 11.3 kg above the ideal weight.

Answer 3

The patient's blood pressure is chronically between 150/80 and 170/90 mm Hg.

Question 4

The nurse is assisting the patient who is recovering from an acute stroke and has right-sided hemiplegia to transfer from the bed to the wheelchair.Which nursing action 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 5

On initial assessment of a patient hospitalized following a stroke,the nurse finds the patient's blood pressure to be 180/90 mm Hg.What should the nurse anticipate?

A) IV fluids will be withheld until the blood pressure is within the normal range.
B) Unless the blood pressure is lowered,the patient is at risk for another stroke.
C) IV fluids will be administered to promote hydration to maintain cerebral perfusion.
D) IV antihypertensive agents will be administered to maintain a mean arterial pressure of 140 mm Hg.

Question 6

Which classification of stroke is the most common one,representing approximately 80% of all strokes?

A) Intercerebral stroke
B) Ischemic stroke
C) Hemorrhagic stroke
D) Subarachnoid stroke

Question 7

During the acute phase of a patient with an ischemic stroke,the nurse monitors the patient's neurological status closely with the knowledge that following a stroke,increased intracranial pressure from cerebral edema is most likely to peak in which of the following time periods?

A) 12 hours
B) 24 hours
C) 48 hours
D) 72 hours

Question 8

The physician recommends a carotid endarterectomy for a patient with carotid atherosclerosis and a history of TIAs.The patient asks the nurse whether this procedure involves brain surgery.In responding to the patient,what should the nurse include information about?

A) An endarterectomy involves brain surgery because plaques in arteries at the base of the brain are removed.
B) This surgery involves resection of a diseased portion of the artery in the brain and replacing it with a synthetic graft.
C) A carotid endarterectomy involves removal of plaques in an artery in the neck and does not involve surgery in the brain.
D) In this surgery,a burr hole is drilled in the skull to connect an artery outside the skull to one inside the brain,bypassing a blockage.

Question 9

Twenty-four hours after admission,a patient with a stroke has progressive development of neurological deficits with increasing weakness and decreased level of consciousness.What is the primary goal of nursing management of the patient at this time?

A) Protecting the skin from breakdown
B) Monitoring for changes in neurological status
C) Maintaining the patient's respiratory function
D) Preventing joint contractures and muscle atrophy

Question 10

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

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

Question 11

A patient has right-sided paresis and aphasia as a result of a stroke but is attempting to use his left hand for feeding and other activities.When his wife visits,she insists on doing everything for him.What is a nursing diagnosis that is most appropriate in this situation?

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 primary person
D) Risk for ineffective therapeutic regimen management related to functional and communication limitations

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 physician?

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

On the medical unit,the nurse 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,which of the following will the nurse anticipate that the patient may be experiencing?

A) Visual deficits
B) Dysphasia
C) Confusion
D) Poor judgement

Question 14

A 68-year-old man has had several TIAs with temporary hemiparesis and dysarthria that have lasted up to an hour.The nurse encourages the patient to seek immediate medical assistance for any symptoms that last longer than an hour,explaining that permanent disability from a stroke may be reduced if therapy is initiated within 3 hours with the use of which of the following treatments?

A) IV heparin
B) Transluminal angioplasty
C) A surgical endarterectomy
D) tPA

Question 15

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.What is an appropriate nursing intervention to help improve the patient's nutrition?

A) Assist the patient to eat with her left hand.
B) Provide a puréed diet that is easy for the patient to swallow.
C) Stroke the patient's throat while feeding her to stimulate swallowing of food.
D) Provide a wide variety of food choices on the meal tray to stimulate her appetite.

Question 16

A patient with a stroke caused by thrombosis of the middle cerebral artery experiences left-sided paralysis of the upper and lower extremities and facial drooping on the left side.When obtaining admission assessment data about the patient's clinical manifestations,it is most important for the nurse to assess which of the following?

A) The patient's ability to follow commands
B) The patient's visual fields
C) The patient's left-sided reflexes
D) The patient's emotional state

Question 17

Which one of the following manifestations would the nurse expect to assess on a patient with right-brain damage from a stroke?

A) Right-sided hemiplegia
B) Slow performance,cautiousness
C) Aware of deficits,depression
D) Impulsive behaviour

Question 18

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

A) Oral administration of clopidogrel (Plavix)
B) Heparin via continuous intravenous (IV)infusion
C) Prophylactic clipping of cerebral aneurysms
D) Therapy with tPA

Question 19

A patient with homonymous hemianopsia resulting from a stroke has a nursing diagnosis of disturbed sensory perception related to hemianopsia.What is an appropriate nursing intervention that will help the patient learn to compensate for the deficit during the rehabilitation period?

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 affected side.
D) Teach the patient to exercise the eye muscles with full range of motion at least twice a day.

Question 20

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

A) Ask simple questions that can be answered with "yes" or "no."
B) Develop a list of simple words that she can read and practise reciting.
C) Have her practise facial and tongue exercises to improve motor control necessary for speech.
D) Prevent embarrassing her by changing the subject if she does not respond in a timely manner.

Question 21

Following a stroke,a patient has urinary incontinence with an impaired impulse to void.What should a bladder retraining program for the patient include?

A) Limiting fluid intake to 1000 mL/day to reduce urine volume
B) Assisting the patient onto the bedpan or the bedside commode every 2 hours
C) Performing intermittent catheterization after each voiding to check for residual urine
D) Inserting an in-dwelling catheter and clamping and draining the catheter every 4 hours to re-establish bladder tone

Question 22

A patient with left-sided hemiparesis arrives by ambulance at 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 23

Which one of the following manifestations would the nurse expect to assess on a patient with left-brain damage from a stroke?

A) Left-sided hemiplegia
B) Spatial-perceptual deficits
C) Impaired speech-language
D) Impaired time concepts

Question 24

Obesity is a modifiable risk factor for the prevention of stroke.What is the prevalence of obesity in Canada among those aged 18 years and older?

A) 30%
B) 50%
C) 60%
D) 75%

Question 25

A 72-year-old man is being discharged home following a stroke.He is able to walk with assistance but needs help with hygiene,dressing,and eating.The patient's 70-year-old wife has received instruction and practice in necessary areas of care.Which of the following statements by the patient's wife indicates to the nurse that the outcomes for discharge planning have been met?

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

Question 26

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 which of the following medications?

A) Alteplase (tPA)
B) Aspirin (Aggrenox)
C) Warfarin (Coumadin)
D) Nimodipine (Nimotop)

Question 27

In order to assess a patient's receptive speech,what should the nurse do?

A) Ask the patient where she is right now.
B) Show the patient three items,and ask the patient to name them.
C) Instruct the patient to close the eyes,ask if a stone sinks in water,and get her to point to the ceiling.
D) Ask the patient the time of day,what month,and what year it is.

Question 28

A patient who has a history of a 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 physician 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.