Deck 70: Management of Clients with Stroke

Question 1

The critical care nurse explains to the family of a client who is to receive nimodipine following hemorrhagic stroke that the purpose of this drug is to treat

A) dizziness.
B) hypertension.
C) spasticity.
D) vasospasm.

Answer 1

vasospasm.

Question 2

A client had a stroke. A nurse has arranged a consultation with an occupational therapist in order to enhance the client's ability to

A) acquire job skills.
B) feed himself.
C) swallow.
D) use a walker.

Answer 2

feed himself.

Question 3

To best help the client who has the nursing diagnosis Ineffective Coping after a stroke, the nurse would

A) break a long-term goal into smaller pieces.
B) listen to the client carefully and try to understand.
C) place familiar items, such as photos, near the bed.
D) redirect the client when inappropriate behavior occurs.

Answer 3

break a long-term goal into smaller pieces.

Question 4

A client who has had a stroke appears to understand words that are spoken but cannot verbally respond. The nurse clarifies that this type of aphasia is

A) Broca's.
B) global.
C) receptive.
D) Wernicke's.

Question 5

The nurse assesses agnosia in a client who had a CVA. An example of this disturbance would be an inability to

A) read and comprehend writing.
B) recognize eating utensils.
C) see past the midline.
D) use the limbs purposefully.

Question 6

When the spouse of a client who has had a CVA as a result of a cerebral hemorrhage asks the nurse about the client's chances for recovery, the nurse should base a reply on knowledge that with this type of CVA

A) improvement generally occurs over several days.
B) rapid improvement often occurs.
C) recovery is slow and less complete.
D) there is no way to know for sure.

Question 7

A client who has left hemiparesis as a result of stroke is getting out of bed to the chair for the first time. The nurse should position the chair

A) at a right angle to the client's left side.
B) at a right angle to the client's right side.
C) facing away from the side of the bed.
D) facing the side of the bed but within 1 foot.

Question 8

The nursing action that would be appropriate in caring for a client who has experienced stroke because of hemorrhage is to

A) maintain the head of the bed in a flat position.
B) monitor rectal temperature every 4 hours.
C) teach isometric exercises.
D) teach the client to avoid the Valsalva maneuver.

Question 9

An emergency department nurse is admitting a client with ischemic stroke who is eligible for thrombolytic therapy. The nurse works quickly to provide care, knowing that for this therapy to be effective, it must be administered in a post-stroke time window of

A) 30 minutes.
B) 3 hours.
C) 6 hours.
D) 12 hours.

Question 10

When the client complains about having to perform quadricep-setting exercises, the nurse reminds him that the exercises will enhance ambulation by

A) combating footdrop.
B) diminishing the effects of proprioception.
C) improving balance.
D) strengthening the knee.

Question 11

A client with stroke has a nursing diagnosis of Impaired Verbal Communication and has specific difficulty in verbal expression. The most helpful strategy by the nurse would be to

A) give the client practice in repeating words after the nurse.
B) point to objects and state their names.
C) repeat directions until they are understood.
D) try to do all the speaking for the client.

Question 12

When a client has undergone a carotid endarterectomy and has been returned to the nursing unit with stable vital signs, the nurse should

A) assess neurologic status every 4 hours.
B) keep the client in a flat, supine position with the head flexed.
C) maintain blood pressure within 20 mm Hg of the preoperative values.
D) provide neck range-of-motion exercises every 8 hours.

Question 13

The nurse encourages a stroke victim by telling them that following a cerebrovascular accident (CVA) caused by thrombosis, the client's condition may improve after several days as a result of

A) decrease of edema in the area.
B) formation of collateral blood circulation.
C) formation of new nervous pathways.
D) reabsorption of the thrombus.

Question 14

Safety precautions the nurse instructs the client with homonymous hemianopsia to use include

A) getting evaluated for prescription lenses.
B) turning the head to scan the visual field.
C) using artificial tears to keep the eyes moist.
D) wearing an eye patch on alternating eyes.

Question 15

A client who had a thrombotic stroke finished receiving intravenous rt-PA therapy at 10:00 AM on Sunday. Sunday afternoon the physician writes an order to start Coumadin and Plavix that evening. The most appropriate action by the nurse would be to

A) call the physician and clarify when the medications should be given.
B) consult with the pharmacist about giving both medications together.
C) give the Coumadin at 5:00 PM because that is the standard administration time.
D) provide appropriate education and administer the medications as ordered.

Question 16

A client has a history of experiencing focal neurologic deficits, such as slurred speech and facial weakness, that last for a few hours at a time. The nurse then assesses this client for other possible manifestations of

A) embolic stroke.
B) encephalopathy.
C) intracranial hemorrhage.
D) transient ischemic attacks (TIAs).

Question 17

To promote safety, when a client complains of the effects of diplopia after a stroke, the nurse would

A) approach the client on the unaffected side.
B) place a patch over one eye.
C) reassure the client that the problem is temporary.
D) teach eye muscle exercises.

Question 18

A client who experienced a stroke that left residual left hemiplegia will not wash the left side or use her good limbs on the right to move or adjust the limbs on the left. The most appropriate diagnosis for this client is

A) Altered Physical Mobility.
B) Ineffective Coping.
C) Self-Care Deficit.
D) Unilateral Neglect.

Question 19

The assessment the nurse documents that supports the finding of apraxia would be the client's inability to

A) get dressed independently.
B) recognize a pencil.
C) see far objects.
D) understand the spoken word.

Question 20

The nurse is caring for a client who had a stroke several years ago. The client has indicators of being malnourished. The nurse would assess the client for which of the following?

A) Ability to throw the head back to propel the food
B) Embarrassment and frustration over trouble eating
C) Inability of the bowel to absorb nutrients
D) Positioning the head with a sideways' tilt

Question 21

The nurse has consulted with the interdisciplinary stroke team to facilitate a client's discharge to home from the rehabilitation facility. The occupational therapist recommends a therapeutic day pass. The nurse explains to the family that the purpose of the pass is to (Select all that apply)

A) allow the client to practice self-care skills.
B) evaluate the accessibility and safety of the home.
C) help the family adjust to the client's presence.
D) improve transition back into the community.
E) reduce the cost of the rehabilitation stay.

Question 22

A nurse teaches a community class about primary prevention for stroke, which includes (Select all that apply)

A) adequate control of hypertension.
B) keeping tight glycemic control in diabetes.
C) maintaining safe cholesterol levels.
D) not smoking or smoking cessation.
E) reducing heavy alcohol consumption.

Question 23

A client has had two TIAs. Priority nursing actions focus on

A) helping the client reduce risk factors for stroke.
B) providing emotional support during this stressful time.
C) teaching the client's family about rehabilitation.
D) working with a speech therapist on speech problems.

Question 24

The nurse would assess the client with a history of TIAs for

A) ataxia and dysarthria.
B) bouts of hypertension.
C) nausea and vomiting.
D) tingling in the extremities.

Question 25

Which interventions should the nurse plan to encourage the client to become proficient in self-administering his/her own medications? (Select all that apply.)

A) Allow the client to assume greater responsibility for taking medications.
B) Create a clear, concise drug chart including all the client's medications.
C) Encourage the client to take medications under supervision of a family member.
D) Provide a supervised trial of self-administration of medications.
E) Teach the client pertinent information about each medication.

Question 26

Self-care measures the nurse or speech therapist should teach the client who has residual dysphagia after a stroke include (Select all that apply)

A) chewing each bite thoroughly.
B) placing foods in the unaffected side of the mouth.
C) sticking to only semi-liquids and very soft foods.
D) turning the head to the unaffected side and checking for retained food.

Question 27

A client has received thrombolytic therapy for treatment of an ischemic stroke. Which intervention takes priority?

A) Assessing nutritional status and planning feeding
B) Consulting with the interdisciplinary stroke team
C) Providing client and family education
D) Stringent blood pressure control

Question 28

A client is admitted to the hospital with right-sided hemiplegia as a result of a stroke. To help prevent contractures, the nurse should employ which of the following interventions? (Select all that apply.)

A) Give the client a ball to hold to keep fingers in the flexed position.
B) Perform passive ROM to affected limbs at least twice a day after the first 24 hours.
C) Support a completely flaccid arm with pillows when in bed or in a chair.
D) Try placing the client in the prone position for 15-30 minutes at a time.
E) Use high-top tennis shoes or orthotics while in bed to prevent footdrop.