Homework Lance
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. A patient with a temporary loss of motor function is diagnosed with a transient ischemic attack (TIA). What should the nurse include when assisting in the teaching about this health problem?
a.
“You had a small hemorrhage in your brain.”
b.
“Your brain was temporarily deprived of oxygen.”
c.
“The neurons in your brain are tangled, so messages get mixed up.”
d.
“You have a vessel that is occluded, blocking the blood supply to your brain.”
____ 2. The nurse is assisting with teaching a patient who has had a transient ischemic attack (TIA). On which understanding should the nurse base teaching?
a.
TIAs are not serious, and the patient should have no further problems.
b.
A TIA is predictive that the patient will have a heart attack within 1 year.
c.
A TIA is a medical emergency that requires immediate surgical intervention.
d.
A TIA is a forewarning that the patient is at risk for a cerebrovascular accident (stroke).
____ 3. The nurse is planning care for a client with right-sided weakness and aphasia from a transient ischemic attack (TIA). Which area of the brain should the nurse realize was affected in this client?
a.
Medulla
b.
Occipital lobe
c.
Left hemisphere
d.
Right hemisphere
____ 4. A patient with a cerebrovascular accident (stroke) has left-sided flaccidity and is unable to speak but seems to understand everything the nurse says. Which term should the nurse use to document the patient’s communication impairment?
a.
Sensory aphasia
b.
Motor dysphagia
c.
Expressive aphasia
d.
Receptive dysphagia
____ 5. The nurse is documenting care provided to a patient with left-sided flaccidity caused by a stroke. Which term should the nurse use to document this patient’s motor status?
a.
Ipsilateral paraplegia
b.
Ipsilateral hemiparesis
c.
Contralateral hemiplegia
d.
Contralateral quadriparesis
____ 6. A patient comes into the emergency department with symptoms of a stroke. Which medication should the nurse expect may be given to the patient if diagnostic testing confirms an ischemic stroke?
a.
Heparin
b.
Clopidogrel (Plavix)
c.
Warfarin (Coumadin)
d.
Tissue-type plasminogen activator (tPA)
____ 7. A patient is prescribed an antiplatelet agent to prevent strokes. Which agent was this patient most likely prescribed?
a.
Aspirin
b.
Warfarin (Coumadin)
c.
Acetaminophen (Tylenol)
d.
Tissue-type plasminogen activator (tPA)
____ 8. A patient with symptoms of impending stroke is scheduled to have a cerebral angiogram. Which statement should the nurse include when assisting with patient teaching?
a.
“This test is designed to detect vascular lesions in the brain.”
b.
“The angiogram is done to help identify swelling in the brain.”
c.
“We need to do this to evaluate electrical function of the brain.”
d.
“This test is done to examine cerebrospinal fluid for signs of bleeding.”
____ 9. The nurse is caring for a hospitalized patient who has had a stroke and is waiting to be transferred to a rehabilitation facility. What nursing action can best maximize the patient’s rehabilitation potential while awaiting the transfer?
a.
Teach the patient what to expect at the rehabilitation facility.
b.
Keep the patient on bedrest to conserve energy for rehabilitation.
c.
Call the physical therapist for bedside rehabilitation until the transfer.
d.
Turn the patient every 2 hours to prevent pressure ulcers and contractures.
____ 10. The nurse is assisting in preparing a patient for transfer to a rehabilitation facility after a stroke. What should the nurse explain as the goal for rehabilitation?
a.
To monitor neurological status
b.
To cure any effects of the stroke
c.
To maximize remaining abilities
d.
To determine the extent of neurological deficits
____ 11. A patient is admitted to the hospital with a severe headache and photophobia. A lumbar puncture confirms a bleeding aneurysm. What nursing interventions should the nurse anticipate assisting with to prevent increased intracranial pressure (ICP) during the acute phase of illness?
a.
Morphine, dark glasses, and expectorants
b.
Quiet room, head of bed up, and stool softeners
c.
Coughing and deep breathing exercises and tranquilizers
d.
Range of motion exercises, bedside commode, and suctioning as needed
____ 12. A client with a subarachnoid bleed refuses to use a bedpan and becomes angry when denied permission to walk to the bathroom. While waiting to hear from the health care provider (HCP), which action should the nurse take?
a.
Help the patient to get up on a bedside commode
b.
Wait for the neurosurgeon to call back with orders
c.
Page security to restrain the patient from harming the nurse
d.
Administer an as-needed dose of a sedative that is ordered
____ 13. A patient is experiencing bilateral hemiparesis, dysphasia, visual changes, and altered level of consciousness, ataxia, and dysphagia. Which artery was most likely affected in this patient’s stroke?
a.
Carotid
b.
Middle cerebral
c.
Posterior cerebral
d.
Vertebrobasilar/cerebellar
____ 14. The patient is diagnosed with a cerebral vascular accident that has the slowest rate of recovery and the highest probability of causing extensive neurological deficits. For which type of stroke should the nurse plan care for this patient?
a.
Thrombotic stroke
b.
Cerebral aneurysm
c.
Subarachnoid hemorrhage (SAH)
d.
Reversible ischemic neurological deficit (RIND)
____ 15. A patient enters the emergency department with right-sided weakness and vision changes. What assessment finding should be communicated to the registered nurse (RN) or HCP immediately?
a.
Blood glucose 150 mg/dL
b.
Blood pressure 148/92 mm Hg
c.
Onset of symptoms occurred 90 minutes ago
d.
History of transient ischemic attack (TIA) 3 months ago
____ 16. The nurse is reviewing teaching provided to a patient with transient ischemic attack (TIA). Which statement indicates that further teaching is required?”
a.
“The risk factors and symptoms of a TIA are just like those of a stroke.”
b.
“I need to stop smoking to help lower my chances of this happening again.”
c.
“My risk for Alzheimer’s disease is increased now, so I’ll have to stop driving.”
d.
“I recognize how important it is to take my anti-hypertension medications regularly.”
____ 17. A patient began experiencing manifestations of a stroke at 0800 hours. By which time should thrombolytic medications be provided to reverse stroke symptoms?
a.
0900 hours
b.
1250 hours
c.
1400 hours
d.
1660 hours
____ 18. A patient is diagnosed with a stroke that occurred at 12 noon the previous day. When should the nurse plan to begin bedside physical therapy with this patient?
a.
After 5 days
b.
Within 2 to 3 days
c.
By 12 noon on the current day
d.
At least one week after the occurrence
____ 19. The nurse is planning care for a patient with an intracerebral hemorrhage. What should be identified as a goal for this patient?
a.
Maintain blood pressure below 120/80 mm Hg
b.
Resume activities of daily living as soon as possible
c.
Expect to experience transient numbness and tingling
d.
Receive thrombolytic medication therapy within an hour
____ 20. A patient tells the nurse that at times it seems like the mouth muscles do not want to work and the patient’s speech is slurred. What should the nurse realize that the patient is describing?
a.
Diplopia
b.
Dysarthria
c.
Dysphagia
d.
Dysrhythmia
____ 21. The nurse suspects that a patient has vision changes caused by a stroke. What did the nurse assess to make this determination?
a.
Patient asks that all items be placed on the right side of the bed.
b.
Patient turns head away when blood is being drawn from an arm.
c.
Patient looks down at the floor when sitting on the side of the bed.
d.
Patient does not follow with the eyes as the nurse walks around the room.
____ 22. The results of a carotid Doppler study indicate that a patient has stenosis of the left carotid artery. For which diagnostic test should the nurse prepare the patient to have completed next?
a.
MRI
b.
CT scan
c.
Echocardiogram
d.
Carotid angiography
____ 23. A patient has been prescribed pravastatin (Pravachol) to reduce cholesterol level after having a transient ischemic attack (TIA). What possible side effect should the nurse include when teaching the patient about this drug?
a.
Diarrhea
b.
Purple toe
c.
Confusion
d.
Muscle aches
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 24. The nurse is assisting with a community education program about stroke prevention. Which are non-modifiable risk factors for stroke that the nurse should include? (Select all that apply.)
a.
Gender
b.
Obesity
c.
Diabetes
d.
Heredity
e.
Smoking
f.
Elevated blood lipids
____ 25. The nurse is providing care for a patient with expressive aphasia. What should the nurse expect to find in the patient’s plan of care? (Select all that apply.)
a.
Speak loudly.
b.
Use a picture board.
c.
Obtain an interpreter.
d.
Provide pencil and paper.
e.
Speak slowly and clearly.
f.
Gesture or pantomime the message.
____ 26. The nurse is planning information about stroke frequency as part of a community health education program. Which demographic groups should the nurse include that are at higher than average risk for stroke? (Select all that apply.)
a.
Pregnant women
b.
Asian Americans
c.
American Indians
d.
African Americans
e.
Men and women 75 years old or older
f.
Individuals who have had a transient ischemic attack (TIA)
____ 27. The nurse is involved in a blood pressure clinic in the community, and an individual with possible stroke symptoms is brought for evaluation. Which findings in the F.A.S.T. assessment indicate the need to call emergency personnel? (Select all that apply.)
a.
The patient sways when asked to stand still with eyes closed.
b.
The patient is unable to follow directions during the assessment.
c.
The patient is unable to repeat a stated phrase exactly as it was stated.
d.
The patient’s face shows signs of uneven symmetry when asked to smile.
e.
When asked to close the eyes and hold arms straight in front, one arm drifts downward.
____ 28. The LPN has been asked to help a patient eat who has impaired swallowing due to a stroke. What should be included in the plan of care? (Select all that apply.)
a.
Have suction equipment available.
b.
Stay with the patient during meals.
c.
Encourage the patient to eat slowly.
d.
Offer the patient a straw for liquids.
e.
Instruct the patient to try to chew on both sides of the mouth.
f.
Place the patient in high Fowler’s position or in a chair for meals.
____ 29. The nurse is assisting with a community education program related to cerebral vascular accidents. What should be included in a list of symptoms that need immediate medical attention? (Select all that apply.)
a.
Sudden trouble seeing in one or both eyes
b.
Sudden severe headache with no known cause
c.
Sudden confusion, trouble speaking, or understanding
d.
Sudden loss of hearing, ringing in the ears, or stabbing ear pain
e.
Sudden trouble walking, dizziness, or loss of balance or coordination
f.
Sudden numbness or weakness of face, arm, or leg, especially on one side of the body
____ 30. A 56 year old female client asks why the nurse is assessing her for a stroke. Which manifestations did the nurse use to make this assessment decision? (Select all that apply.)
a.
Nausea
b.
Hiccups
c.
Itchy skin
d.
Chest pain
e.
Palpitations
Chapter 49. Nursing Care of Patients With Cerebrovascular Disorders
Answer Section
MULTIPLE CHOICE
1.ANS:B
TIA is a temporary impairment of the cerebral circulation causing neurological impairment that lasts less than 24 hours. A. A hemorrhage would cause a hemorrhagic stroke. D. A fully occluded vessel causes an ischemic stroke. C. Tangled messages refer to Alzheimer’s disease.
PTS:1DIF:Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application
2.ANS:D
About a third of patients who experience a TIA will have a stroke in the future. A. Urgent evaluation of TIA is essential in order to decrease the risk of stroke. B. There are no data related to myocardial infarction (MI) prediction. C. It is not a surgical problem.
PTS:1DIF:Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application
3.ANS:C
Symptom onset is sudden and generally involves one side of the body—the side of the body opposite to the damaged area. A. B. The manifestations of right-sided weakness and aphasia would not be present if the TIA occurred in the medulla or occipital lobe. D. The client would have left-sided manifestations if the TIA occurred in the right hemisphere.
PTS:1DIF:Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis
4.ANS:C
Aphasia may be expressive, in which the patient knows what he or she wants to say but cannot speak or make sense. D. Receptive aphasia is an inability to understand spoken or written words. The patient experiencing receptive aphasia is unable to understand language. B. Dysphagia refers to difficulty swallowing. A. Sensory aphasia is not a type of communication impairment.
PTS:1DIF:Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application
5.ANS:C
A patient with a stroke has symptoms on the opposite side of the stroke, which is called contralateral. One-sided flaccidity is called hemiplegia. A. Ipsilateral means the same side. Para refers to the lower extremities. D. Quad refers to all four extremities; B. Hemiparesis is another term for hemiplegia.
PTS:1DIF:Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application
6.ANS:D
tPA is a thrombolytic agent that can break down the thrombus causing the occlusion, which can potentially prevent or completely reverse the symptoms of an ischemic stroke. A. B. C. Heparin, warfarin, and clopidogrel can help prevent clots but are not effective in breaking up an existing clot.
PTS:1DIF:Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application
7.ANS:A
Aspirin is a platelet aggregation inhibitor. C. Tylenol is an analgesic but does not affect platelet function. B. Warfarin is an anticoagulant. D. tPA is a thrombolytic agent.
PTS:1DIF:Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Analysis
8.ANS:A
A cerebral angiogram may be completed to determine the patency of cerebral vessels and the status of any collateral circulation. D. A lumbar puncture is done to examine cerebrospinal fluid (CSF). B. Edema may be identified by radiography. C. An electroencephalogram (EEG) shows electrical function.
PTS:1DIF:Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application
9.ANS:C
Rehabilitation should begin as soon as the patient is stable. Waiting until the patient is at the rehabilitation facility to begin therapy wastes valuable time. A. Teaching the patient what to expect at the rehabilitation facility will not maximize the patient’s rehabilitation potential. B. Keeping the patient on bedrest could cause further mobility issues. D. Turning the patient every 2 hours to prevent ulcer formation and contractures will not necessarily maximize the patient’s rehabilitation potential.
PTS:1DIF:Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application
10.ANS:C
Rehabilitation can help the patient maximize remaining abilities. A. D. At this point, the patient’s neurological status should be stable, and all the diagnostic work has been completed. B. Cure is not realistic.
PTS:1DIF:Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application
11.ANS:B
A quiet room with minimal stressors, elevated head, and stool softeners can help reduce ICP. A. C. Morphine and tranquilizers are not usually recommended because they can make neurological assessment difficult. A. C. Expectorants can promote coughing, which can raise ICP. C. D. Exercises, moving, and suctioning can also raise ICP.
PTS:1DIF:Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application
12.ANS:D
Patients with subarachnoid hemorrhage are at risk for rebleeding. A. Straining to have a bowel movement and agitation both increase the risk of rebleeding. B. The patient may need to be sedated until the physician can be contacted. C. Bringing in security will be upsetting to the patient and can also increase the risk of raising the BP and bleeding.
PTS:1DIF:Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application
13.ANS:D
These are symptoms of vertebrobasilar/cerebellar occlusion. A. B. C. Carotid and middle or posterior cerebral occlusions are not associated with ataxia or dysphagia.
PTS:1DIF:Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis
14.ANS:C
SAH is caused by rupture of blood vessels on the surface of the brain. This type of infarct has the slowest rate of recovery and the highest probability of leaving the patient with extensive neurological deficits. B. Aneurysms are often asymptomatic if they do not bleed. D. RIND is reversible. A. A thrombotic stroke does not have the slowest rate of recovery.
PTS:1DIF:Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application
15.ANS:C
All the data are significant. However, the onset of symptoms is within the time frame for the patient to receive a thrombolytic. If the nurse acts quickly, the patient’s stroke may be able to be reversed.
PTS:1DIF:Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application
16.ANS:C
There is no association between TIA and the development of Alzheimer’s disease. A. The risk factors, causes, and symptoms of a TIA are identical to a cerebrovascular accident (CVA). Patients who have had a TIA have an increased risk of having a stroke. Treatment, therefore, is mostly focused on minimizing the patient’s risk factors for a stroke. B. D. Modifiable risk factors are those risks that can be changed by treatment, such as treating high blood pressure, or by lifestyle modification, such as stopping smoking.
PTS:1DIF:Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis
17.ANS:B
If a patient experiencing ischemic stroke symptoms receives treatment within 4.5 hours of symptom onset, medication can be provided to resolve the deficits. A. A patient needs to be treated within 4.5 hours and not 1 hour. C. D. This is too long to wait to provide medication to treat the symptoms of a stroke.
PTS:1DIF:Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis
18.ANS:C
Patients should be mobilized within 24 hours if possible to prevent complications of immobility. Physical and occupational therapy are provided to maximize functioning and to progress the patient toward a return to baseline functioning. A. B. D. Waiting to begin physical therapy could reduce the patient’s success with physical rehabilitation.
PTS:1DIF:Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application
19.ANS:A
An intracerebral hemorrhage is usually caused by uncontrolled hypertension. Maintaining blood pressure below 120/80 mm Hg should be the goal for these patients. B. These patient cannot resume activities of daily living until the bleeding is controlled within the brain. C. Transient numbness and tingling could indicate additional brain damage from bleeding. D. Thrombolytic therapy is not indicated for an intracerebral hemorrhage.
PTS:1DIF:Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application
20.ANS:B
Slurred or indistinct speech because of a motor problem or lack of coordination is referred to as dysarthria. A. Diplopia is double vision. C. Dysphasia refers to difficulty swallowing. D. Dysrhythmia is an irregular heartbeat.
PTS:1DIF:Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis
21.ANS:D
If the patient’s eyes do not follow the nurse when moving around the room, there is a good chance that the patient has a deficit in that visual field. A. B. C. Placing items on the right side of the bed, turning the ahead away while blood is being drawn, and looking down at the floor when sitting on the side of the bed do not indicate vision changes caused by a stroke.
PTS:1DIF:Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis
22.ANS:D
Carotid Doppler testing uses ultrasound to detect stenosis of the carotid arteries. Carotid angiography can be done to further determine degree of blockage and help guide treatment. A. B. C. After a carotid Doppler, an MRI, CT scan, or echocardiogram are not indicated.
PTS:1DIF:Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application
23.ANS:D
Muscle pain or aches can signal a serious side effect (rhabdomyolysis) and should be reported. A. B. C. Diarrhea, purple toe, and confusion are not side effects of statins.
PTS:1DIF:Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application
MULTIPLE RESPONSE
24.ANS:A, D
Gender and heredity are not modifiable. B. C. E. F. The patient can control diabetes, heart disease, diet, exercise, lipids, and smoking to some degree.
PTS:1DIF:Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application
25.ANS:B, D
For expressive aphasia, pencil and paper or a picture board can help with communication. A. Speaking loudly is not helpful unless the patient has a hearing deficit also. E. F. Speaking slowly and pantomiming may be helpful for receptive aphasia, not expressive. C. Interpreters are used for language barriers, not for aphasia.
PTS:1DIF:Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application
26.ANS:A, C, D, E, F
Some population groups, such as African Americans, American Indians, Alaskan natives, and Mexican Americans, have a higher than average risk. Recent studies indicate that the risk of stroke may be higher in women during pregnancy and the 6 weeks following childbirth. Patients who have had a TIA have an increased risk of having a stroke; about 24% to 29% of patients who experience a TIA will have a stroke within 5 years. Strokes are most common in people over the age of 75. B. Asian Americans are not as high risk.
PTS:1DIF:Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application
27.ANS:C, D, E
The acronym F.A.S.T. can help identify a stroke. Ask the person to smile: If the face droops or is uneven on one side, it is abnormal. Ask the person to close his or her eyes and hold arms out in front of him or her: If an arm cannot be raised or drifts downward, it is abnormal. Ask the person to say “It is a bright and sunny day”: Any difficulty understanding or speaking is abnormal. Call 911 immediately for any abnormal findings. A. These are all indicators of a possible stroke. Brain cells may be dying. B. Inability to follow instructions is a concern but is not part of the F.A.S.T. assessment.
PTS:1DIF:Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis
28.ANS:A, B, C, F
High Fowler’s position can help reduce aspiration risk. The nurse should stay with the patient and be prepared to use suction in case aspiration does occur. D. Straws and thin liquids increase risk of aspiration. E. The patient should chew on the unaffected side; if he or she chews on the affected side, it is difficult to sense the food, and pocketing may occur. Patients should be encouraged to eat slowly and chew his or her food thoroughly.
PTS:1DIF:Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application
29.ANS:A, B, C, E, F
The five signs or symptoms recognized by the American Heart Association/American Stroke Association include sudden numbness or weakness of face, arm, or leg, especially on one side of the body; sudden confusion, trouble speaking, or understanding; sudden trouble seeing in one or both eyes; sudden trouble walking, dizziness, or loss of balance or coordination; and sudden severe headache with no known cause. D. Sudden loss of hearing, ringing in the ears or ear pain are not manifestations of a stroke.
PTS:1DIF:Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application
30.ANS:A, B, D, E
Women have unique symptoms of a stroke including a sudden onset of nausea, hiccups, chest pain, and palpitations. C. Itchy skin is not a manifestation of a stroke.
PTS:1DIF:Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis
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