Chapter 49 Flashcards
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?
Your brain was temporarily deprived of oxygen.
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 TIA is a forewarning that the patient is at risk for a cerebrovascular accident (stroke).
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?
Left hemisphere
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?
Expressive aphasia
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?
Contralateral hemiplagia
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?
Tpa
A patient is prescribed an antiplatelet agent to prevent strokes. Which agent was this patient most likely prescribed
Aspirin
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?
This test is designed to detect vascular lesions in the brain.”
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?
Call the physical therapist for bedside rehabilitation until the transfer.
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?
To maximize remaining abilities
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?
Quiet room, head of bed up, and stool softeners
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?
Administer an as-needed dose of a sedative that is ordered
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?
Vertebrobasilar/cerebellar
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?
SAH
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?
Onset 90 minutes ago
The nurse is reviewing teaching provided to a patient with transient ischemic attack (TIA). Which statement indicates that further teaching is required?”
My risk for Alzheimer’s disease is increased now, so I’ll have to stop driving.”
A patient began experiencing manifestations of a stroke at 0800 hours. By which time should thrombolytic medications be provided to reverse stroke symptoms?
1250
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?
By noon
The nurse is planning care for a patient with an intracerebral hemorrhage. What should be identified as a goal for this patient?
Maintain blood pressure below 120/80 mm Hg
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?
Dysarthria
The nurse suspects that a patient has vision changes caused by a stroke. What did the nurse assess to make this determination
Patient does not follow with the eyes as the nurse walks around the room.
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?
Angiography
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?
Muscle aches
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.)
Gender
Hereditary
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.)
Picture board
Provide pencil and paper
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.
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)
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.)
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.
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
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.
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.)
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
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.)
Nausea
Hiccups
Chest pain
Palpitations
