Ch.58 MD Flashcards
After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual effects, the nurse anticipates teaching the patient about
a. cerebral aneurysm clipping.
b. heparin intravenous infusion.
c. oral low-dose aspirin therapy.
d. tissue plasminogen activator (tPA).
c.oral low-dose aspirin therapy.
A 68-year-old patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin?
a. The patient has dysphasia.
b. The patient has atrial fibrillation.
c. The patient reports that symptoms began with a severe headache.
d. The patient has a history of brief episodes of right-sided hemiplegia.
c.The patient reports that symptoms began with a severe headache.
A 73-year-old patient with a stroke experiences facial drooping on the right side and right-sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find?
a. Impulsive behavior
b. Right-sided neglect
c. Hyperactive left-sided tendon reflexes
d. Difficulty comprehending instructions
d.Difficulty comprehending instructions
During the change of shift report a nurse is told that a patient has an occluded left posterior cerebral artery. The nurse will anticipate that the patient may have
a. dysphasia.
b. confusion.
c. visual deficits.
d. poor judgment.
c.visual deficits.
When teaching about clopidogrel (Plavix), the nurse will tell the patient with cerebral atherosclerosis
a. to monitor and record the blood pressure daily.
b. that Plavix will dissolve clots in the cerebral arteries.
c. that Plavix will reduce cerebral artery plaque formation.
d. to call the health care provider if stools are bloody or tarry.
d.to call the health care provider if stools are bloody or tarry.
A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which response by the nurse is accurate?
a. “The obstructing plaque is surgically removed from an artery in the neck.”
b. “The diseased portion of the artery in the brain is 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.”
a.“The obstructing plaque is surgically removed from an artery in the neck.”
A patient admitted with possible stroke has been aphasic for 3 hours and his current blood pressure (BP) is 174/94 mm Hg. Which order by the health care provider should the nurse question?
a. Keep head of bed elevated at least 30 degrees.
b. Infuse normal saline intravenously at 75 mL/hr.
c. Administer tissue plasminogen activator (tPA) per protocol.
d. Administer a labetalol (Normodyne) drip to keep BP less than 140/90 mm Hg.
d.Administer a labetalol (Normodyne) drip to keep BP less than 140/90 mm Hg.
A 56-year-old patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously, and health records show a history of several transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for
a. surgical endarterectomy.
b. transluminal angioplasty.
c. intravenous heparin administration.
d. tissue plasminogen activator (tPA) infusion.
d.tissue plasminogen activator (tPA) infusion.
A female patient who had a stroke 24 hours ago has expressive aphasia. The nurse identifies the nursing diagnosis of impaired verbal communication. An appropriate nursing intervention to help the patient communicate is to
a. ask questions that the patient can answer with “yes” or “no.”
b. develop a list of words that the patient can read and practice reciting.
c. have the patient practice her facial and tongue exercises with a mirror.
d. prevent embarrassing the patient by answering for her if she does not respond.
a.ask questions that the patient can answer with “yes” or “no.”
For a patient who had a right hemisphere stroke the nurse establishes a nursing diagnosis of
a. risk for injury related to denial of deficits and impulsiveness.
b. impaired physical mobility related to right-sided hemiplegia.
c. impaired verbal communication related to speech-language deficits.
d. ineffective coping related to depression and distress about disability.
a.risk for injury related to denial of deficits and impulsiveness.
When caring for a patient with a new right-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care?
a. Apply an eye patch to the right eye.
b. Approach the patient from the right side.
c. Place objects needed on the patient’s left side.
d. Teach the patient that the left visual deficit will resolve.
c.Place objects needed on the patient’s left side.
The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to impaired self-feeding ability for a left-handed patient with left-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 right hand.
d. Teach the patient the “chin-tuck” technique.
c.Assist the patient to eat with the right hand.
A 40-year-old patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan?
a. Apply intermittent pneumatic compression stockings.
b. Assist to dangle on edge of bed and assess for dizziness.
c. Encourage patient to cough and deep breathe every 4 hours.
d. Insert an oropharyngeal airway to prevent airway obstruction.
a.
Apply intermittent pneumatic compression stockings.
A 47-year-old patient will attempt oral feedings for the first time since having a stroke. 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.
c.assist the patient into a chair.
A male patient who has right-sided weakness after a stroke is making progress in learning to use the left hand for feeding and other activities. The nurse observes that when the patient’s wife is visiting, she feeds and dresses him. Which nursing diagnosis is most appropriate for the patient?
a. Interrupted family processes related to effects of illness of a family member
b. Situational low self-esteem related to increasing dependence on spouse for care
c. Disabled family coping related to inadequate understanding by patient’s spouse
d. Impaired nutrition: less than body requirements related to hemiplegia and aphasia
c.Disabled family coping related to inadequate understanding by patient’s spouse
Several weeks after a stroke, a 50-year-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention will be best to include in the initial plan for an effective bladder training program?
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.
b.Assist the patient onto the bedside commode
A 72-year-old patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the patient says, “I don’t need the aspirin today. I don’t have a fever.” 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 a fever.
c. Explain that the aspirin is ordered to decrease stroke risk.
d. Call the health care provider to clarify the medication order.
c.Explain that the aspirin is ordered to decrease stroke risk.
A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours. The nurse will anticipate teaching the patient about
a. alteplase (tPA).
b. aspirin (Ecotrin).
c. warfarin (Coumadin).
d. nimodipine (Nimotop).
b.aspirin (Ecotrin).
A 58-year-old patient with a left-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.
d.teach the family that emotional outbursts are common after strokes.
Which stroke risk factor for a 48-year-old male patient in the clinic is most important for the nurse to address?
a. The patient is 25 pounds above the ideal weight.
b. The patient drinks a glass of red wine with dinner daily.
c. The patient’s usual blood pressure (BP) is 170/94 mm Hg.
d. The patient works at a desk and relaxes by watching television.
c.The patient’s usual blood pressure (BP) is 170/94 mm Hg.
A patient in the emergency department with sudden-onset right-sided weakness 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).
d.The patient has atrial fibrillation and takes warfarin (Coumadin).
A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first?
a. Complete blood count (CBC)
b. Chest radiograph (Chest x-ray)
c. 12-Lead electrocardiogram (ECG)
d. Noncontrast computed tomography (CT) scan
d.Noncontrast computed tomography (CT) scan
Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness (LOC). Which nursing diagnosis do they determine 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
d.Risk for aspiration related to inability to protect airway
Which information about the patient who has had a subarachnoid hemorrhage is most important to communicate to the health care provider?
a. The patient complains of having a stiff neck.
b. The patient’s blood pressure (BP) is 90/50 mm Hg.
c. The patient reports a severe and unrelenting headache.
d. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).
b.The patient’s blood pressure (BP) is 90/50 mm Hg.
The nurse is caring for a patient who has been experiencing stroke symptoms for 60 minutes. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)?
a. Assess the patient’s gag and cough reflexes.
b. Determine when the stroke symptoms began.
c. Administer the prescribed short-acting insulin.
d. Infuse the prescribed IV metoprolol (Lopressor).
c.Administer the prescribed short-acting insulin.
After receiving change-of-shift report on the following four patients, which patient should the nurse see first?
a. A 60-year-old patient with right-sided weakness who has an infusion of tPA prescribed
b. A 50-year-old patient who has atrial fibrillation and a new order for warfarin (Coumadin)
c. A 40-year-old patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due
d. A 30-year-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine (Nimotop) scheduled
a.A 60-year-old patient with right-sided weakness who has an infusion of tPA prescribed
The nurse is caring for a patient 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 102 beats/min.
b. The patient has difficulty speaking.
c. The blood pressure is 144/86 mm Hg.
d. There are fine crackles at the lung bases.
b.The patient has difficulty speaking.
A 70-year-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first?
a. Monitor the blood pressure.
b. Send the patient for a computed tomography (CT) scan.
c. Check the respiratory rate and effort.
d. Assess the Glasgow Coma Scale score.
c.Check the respiratory rate and effort.
The home health nurse is caring for an 81-year-old who had a stroke 2 months ago. Based on information shown in the accompanying figure from the history, physical assessment, and physical therapy/occupational therapy, which nursing diagnosis is the highest priority for this patient?
a. Impaired transfer ability
b. Risk for caregiver role strain
c. Ineffective health maintenance
d. Risk for unstable blood glucose level
b.Risk for caregiver role strain
