Question 1

A client who is at high-risk for a cerebrovascular accident has medication ordered to lower their cholesterol and to prophylactically anticoagulate them. What specific agent might be diagnosed for this client?
A) Daily aspirin
B) Heparin
C) Victorin
D) Celebrex

Accepted Answer

Daily aspirin is commonly used for its antiplatelet properties to prevent blood clots, which can reduce the risk of a cerebrovascular accident (stroke) in individuals at high risk.

Question 2

A client tells the nurse that they have transient ischemic attacks. The client reports having undergone a carotid artery surgery. In such a case, what important assessments should be performed by the nurse?
A) Sexual history
B) Motor and sensory responses
C) Blood pressure and weight
D) Frequent neurologic checks

Accepted Answer

Transient ischemic attacks (TIAs) are warning signs of a potential stroke. They occur when there is a temporary disruption in blood flow to the brain, causing neurological symptoms that resolve within 24 hours. Therefore, it is important for the nurse to perform frequent neurologic checks on the client who has reported having TIAs. This will allow for early detection of any changes and prompt intervention to prevent a stroke. Assessing motor and sensory responses may also be important in determining the extent of any neurological deficits. However, a sexual history, blood pressure, and weight may not be as relevant in this specific case.

Question 3

You are caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke do you know this client has?
A) Ischemic
B) Hemorrhagic
C) Right-sided
D) Left-sided

Accepted Answer

An embolus blocking the carotid artery suggests an ischemic stroke, which accounts for the majority of stroke cases. Hemorrhagic stroke would involve bleeding in the brain rather than a blockage, and right-sided or left-sided refers to the location of brain damage rather than the cause of the stroke.

Question 4

A client presents to the walk-in clinic complaining of a migraine. The client is prescribed a neuronal stabilizer. What should the nurse suggest to the client?
A) Avoid crowds.
B) Take drugs only after meals at night.
C) Avoid caffeine and alcohol.
D) Use caution while driving or performing hazardous activities.

Accepted Answer

Neuronal stabilizers can cause drowsiness and impaired coordination, so caution should be used while driving or performing hazardous activities.

Question 5

A client is diagnosed with tension headaches. The nurse recommends massage as a treatment for tension headaches. How does massage help clients with tension headaches?
A) Reduces hypotension
B) Increases appetite
C) Relaxes muscles
D) Relieves migraines

Accepted Answer

Massage helps to relax the muscles, which can alleviate tension headaches.

Question 6

During a class on stroke, a junior nursing student asks what the clinical manifestations of stroke are. What would be the instructor's best answer?
A) "Clinical manifestations of a stroke are highly variable, depending on the cardiovascular health of the client."
B) "Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation."
C) "Clinical manifestations of a stroke generally include aphasia, one-sided flaccidity, and trouble swallowing."
D) "Clinical manifestations of a stroke depend on how quickly the clot can be dissolved."

Accepted Answer

The instructor's best answer would be B because it accurately summarizes the various factors that contribute to the clinical manifestations of a stroke, including the location and extent of the blockage, as well as the presence of collateral circulation. While there can be some variation in symptoms depending on the individual client, this answer provides a clear and comprehensive overview of the main factors that impact clinical presentation.

Question 7

A diabetic client is hospitalized with a TIA. When planning this client's discharge teaching the nurse knows to include which of the following?
A) Signs and symptoms of hyperglycemia
B) Techniques to control blood sugar within normal ranges
C) Signs and symptoms of hypoglycemia
D) How to inject insulin

Accepted Answer

Controlling blood sugar within normal ranges is crucial for a diabetic patient to prevent further complications, including the risk of another TIA or stroke.

Question 8

You are caring for a client with chronic migraines who is prescribed medication. What drug-related instructions should the nurse give the client?
A) Take medication just before going to bed at night.
B) Take medication only when migraine is intense.
C) Take medication as soon as symptoms of the migraine begin.
D) Take medication only during the morning when it's calm and quiet.

Accepted Answer

The nurse should instruct the client to take their migraine medication as soon as they experience symptoms of a migraine, rather than waiting until the migraine is intense, as this could lead to ineffective treatment or the need for a higher dosage. Taking the medication before going to bed at night (choice A) may not coincide with the timing of the migraine or interfere with the client's sleep. Taking the medication only during the morning when it's calm and quiet (choice D) does not account for the timing and unpredictable nature of migraines.

Question 9

While making your initial rounds after coming on shift, you find a client thrashing about in bed complaining of a severe headache. The client tells you the pain is behind their right eye which is red and tearing. What type of headache would you suspect this client of having?
A) Migraine
B) Tension
C) Cluster
D) Sinus

Accepted Answer

The symptoms described, such as severe headache localized behind one eye, redness, and tearing of the eye, are characteristic of a cluster headache. Cluster headaches are known for their intense pain and tend to occur in cyclical patterns or clusters.

Question 10

The nurse is caring for a client with a cerebral aneurysm. Why does the nurse limit the interaction of visitors or family members with the client with an aneurysm?
A) The interaction may cause the client to become violent.
B) The interaction may cause migraine in the client.
C) The stimulation can increase intracranial pressure (ICP) or trigger a seizure.
D) The client may become emotional and lose interest in the treatment.

Accepted Answer

Stimulating activities can cause an increase in intracranial pressure or trigger a seizure, which can have serious consequences for the patient with a cerebral aneurysm. Therefore, limiting visitors or family members can help to reduce the risk of these events occurring.

Question 11

A client, prone to cerebrovascular accidents (CVAs), complains of not being able to breathe freely after swallowing food. What measures can the nurse take to help the client breathe freely?
A) Perform the Heimlich maneuver on the client.
B) Provide adequate water or fluids to the client.
C) Suction the mouth or the pharynx of the client.
D) Perform the Valsalva maneuver on the client.

Accepted Answer

The Heimlich maneuver is a first-aid procedure used to dislodge a foreign object from a person's airway. It is performed by standing behind the person and wrapping your arms around their waist. You then make a fist with one hand and place the thumb side of your fist against the person's abdomen, just above their navel. You then grab your fist with your other hand and pull inward and upward with quick, forceful thrusts. This will help to dislodge the foreign object and allow the person to breathe freely.

Question 12

A client diagnosed with migraine headaches asks the nurse what they can do to help control the headaches and minimize the number of attacks they are having. What instructions should the nurse give this client?
A) Identify and avoid factors that precipitate or intensify an attack.
B) Keep a record of activities following an attack.
C) When an attack occurs stay in a brightly lit area.
D) Write down any adverse drug effects.

Accepted Answer

The most effective way to control and reduce the number of migraine attacks is to identify and avoid triggers. Common triggers include stress, certain foods, changes in sleep patterns, and changes in weather. Keeping a record of activities following an attack or adverse drug effects may also be helpful, but avoiding triggers is the most important intervention. Staying in a brightly lit area during a migraine attack may actually make the headache worse, as many people with migraines are sensitive to light.

Question 13

The nursing instructor is discussing cerebral aneurysms with the junior nursing class. The instructor is talking about medications given to clients with aneurysms. What substances would the instructor tell the students should not be administered to clients with an aneurysm who experience pain?
A) Corticosteroids
B) Opioid analgesics
C) Anticonvulsants
D) Tranquilizers or barbiturates

Accepted Answer

Opioid analgesics should be avoided in clients with cerebral aneurysms experiencing pain because they can mask neurological symptoms and potentially worsen the condition by causing respiratory depression, which can increase intracranial pressure.

Question 14

A community health nurse is presenting a talk on cerebrovascular accidents (or strokes) to a local community group. What signs and symptoms of an impending stroke should the nurse include in her presentation? Select all that apply.
A) Hypersensitivity to light
B) Mental confusion
C) Difficulty understanding
D) Impaired coordination
E) Mild headache

Accepted Answer

Signs and symptoms of an impending stroke include mental confusion, difficulty understanding, impaired coordination, sudden weakness or numbness on one side of the body or face, sudden vision changes, severe headache, and difficulty speaking or slurred speech. Hypersensitivity to light and mild headache are not typical signs of an impending stroke.

Question 15

A critical care nurse is caring for a client with a cerebrovascular accident (CVA) The client is prescribed heparin for treatment. The nurse knows to monitor the client for what adverse effects?
A) Migraine attacks
B) Hemorrhage
C) Respiratory distress
D) High blood pressure

Accepted Answer

Heparin is an anticoagulant that helps prevent clots from forming in the blood vessels. However, it can also lead to an increased risk of bleeding and hemorrhage, which is why the nurse should closely monitor the client for any signs of bleeding such as bruising, easy bleeding or hematoma formation. Migraine attacks, respiratory distress, and high blood pressure are not commonly associated adverse effects of heparin.

Question 16

A family member comes to the clinic to talk to the nurse about a client who has had a stroke on the right side of the brain. The family member is concerned because of the deficits the client is exhibiting. The nurse knows that when a client experiences a stroke on the right side of the brain common deficits include what? Select all that apply.
A) Left-sided hemiplegia
B) Tendency to distractibility
C) Impairment of long-term memory
D) Hyperaware of deficits
E) Neglect of objects and people on the left side

Accepted Answer

A stroke on the right side of the brain typically results in deficits on the opposite side of the body, leading to left-sided hemiplegia (A). Individuals with right-brain strokes often have difficulty with spatial and perceptual abilities, which can manifest as neglect of objects and people on the left side (E), and they may also exhibit a tendency to distractibility (B). Right-brain strokes do not typically result in hyperawareness of deficits; this is more characteristic of left-brain strokes. Impairment of long-term memory is not specifically associated with strokes on one side of the brain or the other.

Question 17

A client is admitted to the Emergency Department with a ruptured cerebral aneurysm. What are the dangers to the client from this ruptured aneurysm? Select all that apply.
A) Disruption of nerve impulses to the brain
B) Building of collateral circulation
C) Interruption of oxygenated blood flow to cells and tissues
D) Neurologic changes from increased ICP
E) Blood collecting in the subarachnoid space

Accepted Answer

The answer of A client is admitted to the Emergency...

Question 18

A client has just been diagnosed with an aneurysm. In planning discharge teaching for this client, what instructions should be delivered by the nurse to the client?
A) Avoid heavy lifting.
B) Include peanut butter, bread, or tart foods in the diet.
C) Take opioid analgesics.
D) Take an herbal form of feverfew.

Accepted Answer

Avoiding heavy lifting is important in preventing aneurysm rupture. Peanut butter, bread, or tart foods are not relevant to aneurysm care. Opioid analgesics or herbal feverfew may not be appropriate, depending on the individual case and medical provider's orders.

Question 19

A client is prescribed warfarin. Client teaching has included instructions to maintain a diet rich in foods that contain vitamin K. What sources of food should the nurse instruct the client to eat?
A) Fish, meats, and vegetable oils
B) Citrus fruits
C) Milk and dairy products
D) Cereals, soybeans, and spinach

Accepted Answer

Warfarin is a medication that acts as a blood thinner by inhibiting Vitamin K, which is essential for blood clotting. It is therefore important for clients taking warfarin to maintain a consistent intake of vitamin K in their diet to ensure that their blood clotting factors remain in balance. Foods that are high in vitamin K include green leafy vegetables such as spinach and kale, cereals, and soybeans. Meats, fish, and vegetable oils have little to no vitamin K. Citrus fruits and milk/dairy products are not significant sources of vitamin K.

Question 20

A client is hospitalized when they present to the Emergency Department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to their presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what?
A) Left-sided stroke
B) Right-sided stroke
C) Cerebral aneurysm
D) Transient ischemic attack

Accepted Answer

The rapid resolution of the neurologic deficits within 6 hours suggests that the client had experienced a transient ischemic attack (TIA) rather than a stroke or cerebral aneurysm. TIAs are temporary blockages of blood flow to the brain that can cause similar symptoms to a stroke but typically resolve within 24 hours. It is important to identify and treat TIAs as they can be a warning sign of a future stroke.

Quiz 38: Caring for Clients With Cerebrovascular Disorders

A client who is at high-risk for a cerebrovascular accident has medication ordered to lower their cholesterol and to prophylactically anticoagulate them. What specific agent might be diagnosed for this client?

A client tells the nurse that they have transient ischemic attacks. The client reports having undergone a carotid artery surgery. In such a case, what important assessments should be performed by the nurse?

You are caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke do you know this client has?

A client presents to the walk-in clinic complaining of a migraine. The client is prescribed a neuronal stabilizer. What should the nurse suggest to the client?

A client is diagnosed with tension headaches. The nurse recommends massage as a treatment for tension headaches. How does massage help clients with tension headaches?

During a class on stroke, a junior nursing student asks what the clinical manifestations of stroke are. What would be the instructor's best answer?

A diabetic client is hospitalized with a TIA. When planning this client's discharge teaching the nurse knows to include which of the following?

You are caring for a client with chronic migraines who is prescribed medication. What drug-related instructions should the nurse give the client?

While making your initial rounds after coming on shift, you find a client thrashing about in bed complaining of a severe headache. The client tells you the pain is behind their right eye which is red and tearing. What type of headache would you suspect this client of having?

The nurse is caring for a client with a cerebral aneurysm. Why does the nurse limit the interaction of visitors or family members with the client with an aneurysm?

A client, prone to cerebrovascular accidents (CVAs) , complains of not being able to breathe freely after swallowing food. What measures can the nurse take to help the client breathe freely?

A client diagnosed with migraine headaches asks the nurse what they can do to help control the headaches and minimize the number of attacks they are having. What instructions should the nurse give this client?

The nursing instructor is discussing cerebral aneurysms with the junior nursing class. The instructor is talking about medications given to clients with aneurysms. What substances would the instructor tell the students should not be administered to clients with an aneurysm who experience pain?

A community health nurse is presenting a talk on cerebrovascular accidents (or strokes) to a local community group. What signs and symptoms of an impending stroke should the nurse include in her presentation? Select all that apply.

A critical care nurse is caring for a client with a cerebrovascular accident (CVA) The client is prescribed heparin for treatment. The nurse knows to monitor the client for what adverse effects?

A client is admitted to the Emergency Department with a ruptured cerebral aneurysm. What are the dangers to the client from this ruptured aneurysm? Select all that apply.

A client has just been diagnosed with an aneurysm. In planning discharge teaching for this client, what instructions should be delivered by the nurse to the client?

A client is prescribed warfarin. Client teaching has included instructions to maintain a diet rich in foods that contain vitamin K. What sources of food should the nurse instruct the client to eat?