Ch. 58 MJ

Question 1

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. prophylactic clipping of cerebral aneurysms.
b. heparin via continuous intravenous infusion.
c. oral administration of low dose aspirin therapy.
d. therapy with tissue plasminogen activator (tPA).

Answer 1

c. oral administration of low dose aspirin therapy.

Question 2

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 dysphasia.
b. The patient has atrial fibrillation.
c. The patient states, “My symptoms started with a terrible headache.”
d. The patient has a history of brief episodes of right-sided hemiplegia.

Answer 2

c. The patient states, “My symptoms started with a terrible headache.”

Question 3

A patient with a stroke experiences right-sided arm and leg paralysis and facial drooping on the right side. When admitting the patient, which clinical manifestation will the nurse expect to find?

a. Impulsive behavior
b. Right-sided neglect
c. Hyperactive left-sided reflexes
d. Difficulty in understanding commands

Answer 3

d. Difficulty in understanding commands

Question 4

The nurse receives a verbal report that a patient has an occlusion of the left posterior cerebral artery. The nurse will anticipate that the patient may have

a. dysphasia.
b. confusion.
c. visual deficits.
d. poor judgment.

Answer 4

c. visual deficits.

Question 5

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. to monitor and record the blood pressure daily.
b. to call the health care provider if stools are tarry.
c. that Plavix will dissolve clots in the cerebral arteries.
d. that Plavix will reduce cerebral artery plaque formation.

Answer 5

b. to call the health care provider if stools are tarry.

Question 6

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

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

Answer 6

a. “The carotid endarterectomy involves surgical removal of plaque from an artery in the neck.”

Question 7

When assessing a patient with a possible stroke, the nurse finds that the patient’s aphasia started 3.5 hours previously and the blood pressure is 170/92 mm Hg. Which of these 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

Answer 7

d. Titrate labetolol (Normodyne) drip to keep BP less than 140/90 mm Hg

Question 8

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

a. surgical endarterectomy.
b. transluminal angioplasty.
c. intravenous heparin administration.
d. tissue plasminogen activator (tPA) infusion.

Answer 8

d. tissue plasminogen activator (tPA) infusion.

Question 9

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. have the patient practice facial and tongue exercises.
b. ask simple questions that the patient can answer with “yes” or “no.”
c. develop a list of words that the patient can read and practice reciting.
d. prevent embarrassing the patient by changing the subject if the patient does not respond.

Answer 9

b. ask simple questions that the patient can answer with “yes” or “no.”

Question 10

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. risk for injury related to denial of deficits and impulsiveness.
c. impaired verbal communication related to speech-language deficits.
d. ineffective coping related to depression and distress about disability.

Answer 10

b. risk for injury related to denial of deficits and impulsiveness.

Question 11

When caring for a patient with left-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care during the acute period of the stroke?

a. Apply an eye patch to the left eye.
b. Approach the patient from the left side.
c. Place objects needed for activities of daily living on the patient’s right side.
d. Reassure the patient that the visual deficit will resolve as the stroke progresses.

Answer 11

c. Place objects needed for activities of daily living on the patient’s right side.

Question 12

The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to impaired self-feeding ability for a patient with right-sided hemiplegia. Which intervention should be included in the plan of care?

a. Provide a wide variety of food choices.
b. Provide oral care before and after meals.
c. Assist the patient to eat with the left hand.
d. Teach the patient the “chin-tuck” technique.

Answer 12

c. Assist the patient to eat with the left hand.

Question 13

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. Applying intermittent pneumatic compression stockings
b. Assisting to dangle on edge of bed and assess for dizziness
c. Encouraging patient to cough and deep breathe every 4 hours
d. Inserting an oropharyngeal airway to prevent airway obstruction

Answer 13

a. Applying intermittent pneumatic compression stockings

Question 14

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. order a varied pureed diet.
b. assess the patient’s appetite.
c. assist the patient into a chair.
d. offer the patient a sip of juice.

Answer 14

c. assist the patient into a chair.

Question 15

A patient who has right-sided weakness after a stroke 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.” Which nursing diagnosis is most appropriate for the patient?

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. Impaired nutrition: less than body requirements related to hemiplegia and aphasia

Answer 15

c. Disabled family coping related to inadequate understanding by patient’s spouse

Question 16

Several weeks after a stroke, a patient has urinary incontinence resulting from an impaired awareness of bladder fullness. For an effective bladder training program, which nursing intervention will be best to include in the plan of care?

a. Limit fluid intake to 1200 mL daily to reduce urine volume.
b. Assist the patient onto the bedside commode every 2 hours.
c. Perform intermittent catheterization after each voiding to check for residual urine.
d. Use an external “condom” catheter to protect the skin and prevent embarrassment.

Answer 16

b. Assist the patient onto the bedside commode every 2 hours.

Question 17

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. Tell the patient that the aspirin is used to prevent aches.
c. Explain that the aspirin is ordered to decrease stroke risk.
d. Call the health care provider to clarify the medication order.

Answer 17

c. Explain that the aspirin is ordered to decrease stroke risk.

Question 18

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)

Answer 18

b. aspirin (Ecotrin).

Question 19

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

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

Answer 19

d. teach the family that emotional outbursts are common after strokes.

Question 20

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 has a daily glass of wine to relax.
b. The patient is 25 pounds above the ideal weight.
c. The patient works at a desk and relaxes by watching television.
d. The patient’s blood pressure (BP) is usually about 180/90 mm Hg.

Answer 20

d. The patient’s blood pressure (BP) is usually about 180/90 mm Hg.

Question 21

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’s speech is difficult to understand.
b. The patient’s blood pressure is 144/90 mm Hg.
c. The patient takes a diuretic because of a history of hypertension.
d. The patient has atrial fibrillation and takes warfarin (Coumadin).

Answer 21

d. The patient has atrial fibrillation and takes warfarin (Coumadin).

Question 22

A patient with right-sided weakness that started 90 minutes earlier is admitted to the emergency department and all these diagnostic tests are ordered. Which test should be done first?

a. Electrocardiogram (ECG)
b. Complete blood count (CBC)
c. Chest radiograph (Chest x-ray)
d. Noncontrast computed tomography (CT) scan

Answer 22

d. Noncontrast computed tomography (CT) scan

Question 23

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

a. Impaired physical mobility related to weakness
b. Disturbed sensory perception related to brain injury
c. Risk for impaired skin integrity related to immobility
d. Risk for aspiration related to inability to protect airway

Answer 23

d. Risk for aspiration related to inability to protect airway

Question 24

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’s blood pressure is 90/50 mm Hg.
b. The patient complains about having a stiff neck.
c. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).
d. The patient complains of an ongoing severe headache.

Answer 24

a. The patient’s blood pressure is 90/50 mm Hg.

Question 25

Which of these nursing actions included in the care of a patient who has been experiencing stroke symptoms for 60 minutes can the nurse delegate to an LPN/LVN?

a. Assess the patient’s gag and cough reflexes.
b. Determine when the stroke symptoms began.
c. Administer the prescribed clopidogrel (Plavix).
d. Infuse the prescribed IV metoprolol (Lopressor).

Answer 25

c. Administer the prescribed clopidogrel (Plavix).

Question 26

After receiving change-of-shift report on the following four patients, which patient should the nurse see first?

a. A patient with right-sided weakness who has an infusion of tPA prescribed
b. A patient who has atrial fibrillation and a new order for warfarin (Coumadin)
c. A patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due
d. A patient with a subarachnoid hemorrhage 2 days ago who has nimodipine (Nimotop) scheduled

Answer 26

a. A patient with right-sided weakness who has an infusion of tPA prescribed

Question 27

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. The patient has difficulty talking.
c. The blood pressure is 142/88 mm Hg.
d. There are fine crackles at the lung bases.

Answer 27

b. The patient has difficulty talking.

Question 28

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

a. Check the respiratory rate.
b. Monitor the blood pressure.
c. Send the patient for a CT scan.
d. Obtain the Glasgow Coma Scale score.

Answer 28

a. Check the respiratory rate.