Hinkle 62 Flashcards
A nurse is assisting a client who had a recent stroke with getting dressed for physical
therapy. The client looks at each piece of clothing before putting it on the body. The
client states, “This is how I know what item I am holding.” What impairment is this client
likely experiencing?
A. Homonymous hemianopsia
B. Receptive aphasia
C. Agnosia
D. Hemiplegia
ANS: C
Rationale: Agnosia is the loss of the ability to recognize objects through a particular
sensory system; it may be visual, auditory, or tactile. The client was able to see what was
being held but was not recognizing specific garments by just touching them. Because the
client was able to see homonymous hemianopsia, which is blindness in half of the visual
field in one or both eyes, is unlikely. Receptive aphasia is an inability to understand
language. Hemiplegia is a motor/ambulatory dysfunction. The presented scenario did not
support these findings.
A client with a left hemispheric stroke is having difficulty with their normal speech
patterns. The nurse is not sure whether the client has expressive aphasia or apraxia.
Which statement would most likely be reflective of apraxia?
A. The nurse gives direction to get out of bed but the client does not understand.
B. The client points and gestures to an object needed on the overhead table.
C. The client starts by saying “good morning” but finishes with saying “good day” to
the nurse.
D. The client sits
ANS: C
Rationale: Apraxia is an inability to perform a previously learned action as may be seen
when a client makes verbal substitutions for desired syllables or words. The client
changed “good morning” to “good day,” which is suggestive of this condition. Aphasia
which can be expressive aphasia (inability to express oneself) or receptive aphasia
(inability to understand language) is more likely represented with the client being unable
to understand directions to get out of bed and by pointing and gesturing to an object
needed rather than speaking. The client turning to one side so he/she can see the object
may be more indicative of blindness to one side (homonymous hemianopsia).
A client with a recent stroke history is admitted to a rehabilitation unit and placed on
high fall risk precautions. The client is impulsive, easily distracted, frequently forgets
his/her cane when walking, and the location of his/her room. What stroke conditions do
these signs best indicate?
A. Ischemic stroke
B. Right hemispheric stroke
C. Hemorrhagic stroke
D. Left hemispheric stroke
ANS: B
Rationale. In right hemispheric stroke, signs include a client that is easily distracted and
has impulsive behavior and poor judgment. The client can be unaware of deficits like
motor weakness, as demonstrated by the client forgetting the cane. Clients can also have
spatial or perceptual deficits. This means they can get lost in familiar and unfamiliar
places. This client was unable to find his/her room. The client who has a right hemisphere
stroke demonstrates weakness on the left side of the body. The client with left
hemispheric stroke has signs such as paralysis or weakness in the right side of the body,
right-sided visual deficits, and slow cautious behaviors. Ischemic and hemorrhagic
strokes describe what caused the stroke rather than what side of the brain was affected.
Signs and symptoms differ for each type of stroke. Ischemic strokes can include
numbness to one side of the face. Headache, decreased level of consciousness, and
seizures typically are signs of a hemorrhagic stroke.
A client diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid
endarterectomy. The nurse explains that this procedure will be done for which purpose?
A. To decrease cerebral edema
B. To prevent seizure activity that is common following a TIA
C. To remove atherosclerotic plaques blocking cerebral flow
D. To determine the cause of the TIA
ANS: C
Rationale: The main surgical procedure for select clients with TIAs is carotid
endarterectomy, the removal of an atherosclerotic plaque or thrombus from the carotid
artery to prevent stroke in clients with occlusive disease of the extracranial arteries. An
endarterectomy does not decrease cerebral edema, prevent seizure activity, or
determine the cause of a TIA.
The nurse is discharging home a client who had a stroke. The client has a flaccid right
arm and leg and is experiencing urinary incontinence. The nurse makes a referral to a
home health nurse because of an awareness of what common client response to a change
in body image?
A. Confusion
B. Uncertainty
C. Depression
D. Disassociation
ANS: C
Rationale: Depression is a common and serious problem in the client who has had a
stroke. It can result from a profound disruption in his or her life and changes in total
function, leaving the client with a loss of independence. The nurse needs to encourage
the client to verbalize feelings to assess the effect of the stroke on self-esteem.
Confusion, uncertainty, and disassociation are not the most common client response to a
change in body image, although each can occur in some clients.
The nurse is caring for a client who had a hemorrhagic stroke. What assessment
finding constitutes an early sign of deterioration?
A. Generalized pain
B. Alteration in level of consciousness (LOC)
C. Tonic-clonic seizures
D. Shortness of breath
ANS: B
Rationale: Alteration in LOC is the earliest sign of deterioration in a client after a
hemorrhagic stroke, such as mild drowsiness, slight slurring of speech, and sluggish
papillary reaction. Sudden headache may occur, but generalized pain is less common.
Seizures and shortness of breath are not identified as early signs of hemorrhagic stroke.
A client with an ischemic stroke has been brought to the emergency room. The health
care provider institutes measures to restore cerebral blood flow. What area of the brain
would most likely benefit from this immediate intervention?
A. Cerebral cortex
B. Temporal lobe
C. Central sulcus
D. Penumbra region
ANS: D
Rationale: In an ischemic stroke, there is disruption of the cerebral blood flow due to
obstruction of a blood vessel. This disruption in blood flow initiates a complex series of
cellular metabolic events referred to as the ischemic cascade. Early in the cascade, an
area of low cerebral blood flow, referred to as the penumbra region, exists around the
area of infarction. The penumbra region is ischemic brain tissue that may be salvaged
with timely intervention. The cerebral cortex, temporal lobe, and central sulcus are all
different areas of the brain. Since the specific area was not identified in the scenario; the
area that would most benefit from immediate interventions would be the area
surrounding the infarct called the penumbra region.
A rapid response and stroke alert/code has been called for a client with deep vein
thrombosis (DVT) of the left leg being treated with intravenous heparin. The client’s
international normalized ratio (INR) is 2.1 and vital signs are: Temperature 100.1°F
(37.8°C), heart rate 102, blood pressure 190/100, respirations 14, and saturation 89%
on room air. What are priority interventions for a client who is currently on anticoagulant
therapy and having an ischemic stroke?
A. Immediate intubation and urinary catheter placement
B. Supplemental oxygen and monitoring blood glucose levels
C. Antipyretics in order to keep the client in a state of hypothermia
D. Antihypertensive medications and vital signs every two hours
ANS: B
Rationale: Careful maintenance of cerebral hemodynamics to maintain cerebral perfusion
is extremely important after a stroke. Interventions during this period include measures
to reduce ICP. Other treatment measures include: Providing supplemental oxygen if
saturation is below 95% and monitoring of blood glucose and management. Intubation is
used only if necessary to establish a patent airway. For this client, a more expedient and
less invasive measure would be supplemental oxygen. Urinary catheter placement is not
a priority measure for this client. It is important to monitor for febrile events, but there is
no protocol in place to keep the client hypothermic. Antihypertensive medication goals
for blood pressure in the first 24 hours after a stroke remain controversial for a client who
has not received thrombolytic therapy; antihypertensive treatment may be given to
lower the blood pressure by 15% if the systolic blood pressure exceeds 220 mm Hg or the
diastolic blood pressure exceeds 120 mm Hg. Vital signs for this client would be
monitored closely and continuously until stable.
A client with a cerebral aneurysm exhibits signs and symptoms of an increase in
intracranial pressure (ICP). What nursing intervention would be most appropriate for this
client?
A. Passive range-of-motion exercises to prevent contractures
B. Supine positioning
C. Early initiation of physical therapy
D. Absolute bed rest in a quiet, non stimulating environment
ANS: D
Rationale: The client is placed on immediate and absolute bed rest in a quiet,
nonstressful environment because activity, pain, and anxiety elevate BP, which increases
the risk for bleeding. Visitors are restricted. The nurse administers all personal care. The
client is fed and bathed to prevent any exertion that might raise BP. Clients with
increased ICP are normally positioned with the HOB elevated.
A client recovering from a stroke has severe shoulder pain from subluxation of the
shoulder. To prevent further injury and pain, the nurse caring for this client is aware of
what principle of care?
A. The client should be fitted with a cast because use of a sling should be avoided
due to adduction of the affected shoulder.
B. Elevation of the arm and hand can lead to further complications associated with
edema.
C. Passively exercising the affected extremity is avoided in order to minimize pain.
D. The client should be taught to interlace fingers, place palms together, and slowly
bring scapulae forward to avoid excessive force to shoulder.
ANS: D
Rationale: To prevent shoulder pain, the nurse should never lift a client by the flaccid
shoulder or pull on the affected arm or shoulder. The client is taught how to move and
exercise the affected arm/shoulder through proper movement and positioning. The client
is instructed to interlace the fingers, place the palms together, and push the clasped
hands slowly forward to bring the scapulae forward; he or she then raises both hands
above the head. This is repeated throughout the day. The use of a properly worn sling
when the client is out of bed prevents the paralyzed upper extremity from dangling
without support. Range-of-motion exercises are still vitally important in preventing a
frozen shoulder and ultimately atrophy of subcutaneous tissues, which can cause more
pain. Elevation of the arm and hand is also important in preventing dependent edema of
the hand.
The client has been diagnosed with aphasia after suffering a stroke. What can the
nurse do to best make the client’s atmosphere more conducive to communication?
A. Provide a board of commonly used needs and phrases.
B. Have the client speak to loved ones on the phone daily.
C. Help the client complete his or her sentences as needed.
D. Speak in a loud and deliberate voice to the client.
ANS: A
Rationale: The inability to talk on the telephone or answer a question or exclusion from
conversation causes anger, frustration, fear of the future, and hopelessness. A
common
pitfall is for the nurse or other health care team member to complete the thoughts or
sentences of the client. This should be avoided because it may cause the client to feel
more frustrated at not being allowed to speak and may deter efforts to practice putting
thoughts together and completing a sentence. The client may also benefit from a
communication board, which has pictures of commonly requested needs and phrases.
The board may be translated into several languages.
The nurse is caring for a client diagnosed with an ischemic stroke and knows that
effective positioning of the client is important. Which of the following should be integrated
into the client’s plan of care?
A. The client’s hip joint should be maintained in a flexed position.
B. The client should be in a supine position unless ambulating.
C. The client should be placed in a prone position for 15 to 30 minutes several times
a day.
D. The client should be placed in a Trendelenburg position two to three times daily
to promote cerebral perfusion.
ANS: C
Rationale: If possible, the clients placed in a prone position for 15 to 30 minutes several
times a day. A small pillow or a support is placed under the pelvis, extending from the
level of the umbilicus to the upper third of the thigh. This helps to promote
hyperextension of the hip joints, which is essential for normal gait, and helps prevent
knee and hip flexion contractures. The hip joints should not be maintained in flexion and
the Trendelenburg position is not indicated.
The nurse is assessing a client with a suspected stroke. What assessment finding is
most suggestive of a stroke?
A. Facial droop
B. Dysrhythmias
C. Periorbital edema
D. Projectile vomiting
ANS: A
Rationale: Facial drooping or asymmetry is a classic abnormal finding on a physical
assessment that may be associated with a stroke. Periorbital edema (swelling around the
eyes) is not suggestive of a stroke, and clients less commonly experience dysrhythmias
or vomiting.
The nurse is educating a group of students about complications of an aneurysm.
Which is a complication of aneurysm?
A. Seizure
B. Hypernatremia
C. Airway collapse
D. Pneumothorax
ANS: A
Rationale: Due to increased intracranial pressure, there is a risk for the client developing
seizures. Hyponatremia, not hypernatremia, can occur. Airway collapse and
pneumothorax do not occur as a complication of an aneurysm.
The nurse is preparing health education for a client who is being discharged after
hospitalization for a hemorrhagic stroke. What content should the nurse include in this
education?
A. Mild, intermittent seizures can be expected.
B. Take ibuprofen for a serious headache.
C. Take antihypertensive medication as prescribed.
D. Drowsiness is normal for the first week after discharge.
ANS: C
Rationale: The client and family are provided with information that will enable them to
cooperate with the care and restrictions required during the acute phase of hemorrhagic
stroke and to prepare the client to return home. Client and family teaching includes
information about the causes of hemorrhagic stroke and its possible consequences.
Symptoms of hydrocephalus include gradual onset of drowsiness and behavioral
changes. Hypertension is the most serious risk factor, suggesting that appropriate
antihypertensive treatment is essential for a client being discharged. Seizure activity is
not normal; reports of a serious headache should be reported to the health care provider
before any medication is taken. Drowsiness is not normal or expected.
A nurse is caring for a client diagnosed with a hemorrhagic stroke. When creating this
client’s plan of care, what goal should be prioritized?
A. Prevent complications of immobility.
B. Maintain and improve cerebral tissue perfusion.
C. Relieve anxiety and pain.
D. Relieve sensory deprivation.
ANS: B
Rationale: Each of the listed goals is appropriate in the care of a client recovering from a
stroke. However, promoting cerebral perfusion is a priority physiologic need, on which
the client’s survival depends.
. A client diagnosed with a cerebral aneurysm reports a severe headache to the nurse.
What action is a priority for the nurse?
A. Sit with the client for a few minutes.
B. Administer an analgesic.
C. Inform the nurse manager.
D. Call the health care provider immediately.
ANS: D
Rationale: A headache may be an indication that the aneurysm is leaking. The nurse
should notify the health care provider immediately. The health care provider will decide
whether administration of an analgesic is indicated. Informing the nurse manager is not
necessary. Sitting with the client is appropriate, once the health care provider has been
notified of the change in the client’s condition.
A client is brought by ambulance to the ED after suffering what the family thinks is a
stroke. The nurse caring for this client is aware that an absolute contraindication for
thrombolytic therapy is what?
A. Evidence of hemorrhagic stroke
B. Blood pressure of 180/110 mm Hg
C. Evidence of stroke evolution
D. Previous thrombolytic therapy within the past 12 months
ANS: A
Rationale: Thrombolytic therapy would exacerbate a hemorrhagic stroke with potentially
fatal consequences. Stroke evolution, high BP, or previous thrombolytic therapy does not
contraindicate its safe and effective use.
- When caring for a client who has had a stroke, a priority is reduction of ICP. What
client position is most consistent with this goal?
A. Head turned slightly to the right side
B. Elevation of the head of the bed
C. Position changes every 15 minutes while awake
D. Extension of the neck
ANS: B
Rationale: Elevation of the head of the bed promotes venous drainage and lowers ICP;
the nurse should avoid flexing or extending the neck or turning the head side to side. The
head should be in a neutral midline position. Excessively frequent position changes are
unnecessary.
A client who suffered an ischemic stroke now has disturbed sensory perception. What
principle should guide the nurse’s care of this client?
A. The client should be approached on the side where visual perception is intact.
B. Attention to the affected side should be minimized in order to decrease anxiety.
C. The client should avoid turning in the direction of the defective visual field to
minimize shoulder subluxation.
D. The client should be approached on the opposite side of where the visual
perception is intact to promote recovery.
NS: A
Rationale: Clients with decreased field of vision should first be approached on the side
where visual perception is intact. All visual stimuli should be placed on this side. The
client can and should be taught to turn the head in the direction of the defective visual
field to compensate for this loss. The nurse should constantly remind the client of the
other side of the body and should later stand at a position that encourages the client to
move or turn to visualize who and what is in the room.
What should be included in the client’s care plan when establishing an exercise
program for a client affected by a stroke?
A. Schedule passive range of motion every other day.
B. Keep activity limited, as the client may be overstimulated.
C. Have the client perform active range-of-motion (ROM) exercises once a day.
D. Exercise the affected extremities passively four or five times a day.
ANS: D
Rationale: The affected extremities are exercised passively and put through a full ROM
four or five times a day to maintain joint mobility, regain motor control, prevent
development of a contracture in the paralyzed extremity, prevent further deterioration of
the neuromuscular system, and enhance circulation. Active ROM exercises should ideally
be performed more than once per day.
A client is diagnosed with a right-sided stroke. The client is now experiencing
hemianopsia. How might the nurse help the client manage the potential sensory and
perceptional difficulties?
A. Keep the lighting in the client’s room low.
B. Place the client’s clock on the affected side.
C. Approach the client on the side where vision is impaired.
D. Place the client’s extremities where the client can see them.
ANS: D
Rationale: The client with homonymous hemianopsia (loss of half of the visual field) turns
away from the affected side of the body and tends to neglect that side and the space on
that side; this is called amorphosynthesis. In such instances, the client cannot see food
on half of the tray, and only half of the room is visible. It is important for the nurse to
remind the client constantly of the other side of the body, to maintain alignment of the
extremities, and if possible, to place the extremities where the client can see them.
Clients with a decreased field of vision should be approached on the side where visual
perception is intact. All visual stimuli (clock, calendar, and television) should be placed on
this side. The client can be taught to turn the head in the direction of the defective visual
field to compensate for this loss. Increasing the natural or artificial lighting in the room
and providing eyeglasses are important in increasing vision. There is no reason to keep
the lights dim.
