Chapter 49

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?

Answer 1

Your brain was temporarily deprived of oxygen.

Question 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?

Answer 2

A TIA is a forewarning that the patient is at risk for a cerebrovascular accident (stroke).

Question 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?

Answer 3

Left hemisphere

Question 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?

Answer 4

Expressive aphasia

Question 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?

Answer 5

Contralateral hemiplagia

Question 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?

Answer 6

Tpa

Question 7

A patient is prescribed an antiplatelet agent to prevent strokes. Which agent was this patient most likely prescribed

Answer 7

Aspirin

Question 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?

Answer 8

This test is designed to detect vascular lesions in the brain.”

Question 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?

Answer 9

Call the physical therapist for bedside rehabilitation until the transfer.

Question 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?

Answer 10

To maximize remaining abilities

Question 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?

Answer 11

Quiet room, head of bed up, and stool softeners

Question 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?

Answer 12

Administer an as-needed dose of a sedative that is ordered

Question 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?

Answer 13

Vertebrobasilar/cerebellar

Question 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?

Answer 14

SAH

Question 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?

Answer 15

Onset 90 minutes ago

Question 16

The nurse is reviewing teaching provided to a patient with transient ischemic attack (TIA). Which statement indicates that further teaching is required?”

Answer 16

My risk for Alzheimer’s disease is increased now, so I’ll have to stop driving.”

Question 17

A patient began experiencing manifestations of a stroke at 0800 hours. By which time should thrombolytic medications be provided to reverse stroke symptoms?

Answer 17

1250

Question 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?

Answer 18

By noon

Question 19

The nurse is planning care for a patient with an intracerebral hemorrhage. What should be identified as a goal for this patient?

Answer 19

Maintain blood pressure below 120/80 mm Hg

Question 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?

Answer 20

Dysarthria

Question 21

The nurse suspects that a patient has vision changes caused by a stroke. What did the nurse assess to make this determination

Answer 21

Patient does not follow with the eyes as the nurse walks around the room.

Question 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?

Answer 22

Angiography

Question 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?

Answer 23

Muscle aches

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.)

Answer 24

Gender

Hereditary

Question 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.)

Answer 25

Picture board

Provide pencil and paper

Question 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.

Answer 26

Pregnant women
Asian Americans
American Indians
African Americans
Men and women 75 years old or older
Individuals who have had a transient ischemic attack (TIA)

Question 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.)

Answer 27

The patient is unable to repeat a stated phrase exactly as it was stated.
The patient’s face shows signs of uneven symmetry when asked to smile.
When asked to close the eyes and hold arms straight in front, one arm drifts downward.

Question 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 app

Answer 28

Have suction equipment available
Stay with the patient during meals.
Encourage the patient to eat slowly.
Place the patient in high Fowler’s position or in a chair for meals.

Question 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.)

Answer 29

Sudden trouble seeing in one or both eyes
Sudden severe headache with no known cause
Sudden confusion, trouble speaking, or understanding
Sudden trouble walking, dizziness, or loss of balance or coordination
Sudden numbness or weakness of face, arm, or leg, especially on one side of the body

Question 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.)

Answer 30

Nausea
Hiccups
Chest pain
Palpitations