Med Surg - Exam 2 - Ch 58 (Stroke)

Question 1

Of the following patients, the nurse recognizes that the one with the highest risk for a stroke is a(n)

a. obese 45-year-old Native American.
b. 35-year-old Asian American woman who smokes.
c. 32-year-old white woman taking oral contraceptives.
d. 65-year-old African American man with hypertension.

Answer 1

d. 65-year-old African American man with hypertension.

Nonmodifiable risk factors for stroke include age (older than 65 years), male gender, ethnicity or race (incidence is highest in African Americans; next highest in Hispanics, Native Americans/Alaska Natives, and Asian Americans; and next highest in white people), and family history of stroke or personal history of a transient ischemic attack or stroke. Modifiable risk factors for stroke include hypertension (most important), heart disease (especially atrial fibrillation), smoking, excessive alcohol consumption (causes hypertension), abdominal obesity, sleep apnea, metabolic syndrome, lack of physical exercise, poor diet (high in saturated fat and low in fruits and vegetables), and drug abuse (especially cocaine). Other risk factors for stroke include a diagnosis of diabetes mellitus, increased serum levels of cholesterol, birth control pills (high levels of progestin and estrogen), history of migraine headaches, inflammatory conditions, hyperhomocystinemia, and sickle cell disease.

Question 2

A thrombus that develops in a cerebral artery does not always cause a loss of neurologic function because

a. the body can dissolve atherosclerotic plaques as they form.
b. some tissues of the brain do not require constant blood supply to prevent damage.
c. circulation via the circle of Willis may provide blood supply to the affected area of the brain.
d. neurologic deficits occur only when major arteries are occluded by thrombus formation around atherosclerotic plaque.

Answer 2

c. circulation via the circle of Willis may provide blood supply to the affected area of the brain.

The communication between the anterior and posterior cerebral circulation in the circle of Willis provides a collateral circulation, which may maintain circulation to an area of the brain if its original blood supply is obstructed. All areas of the brain require constant blood supply and atherosclerotic plaques are not readily reversed. Neurologic deficits can result from ischemia caused by many factors.

Question 3

A patient comes to the emergency department immediately after experiencing numbness of the face and an inability to speak but while the patient awaits examination, the symptoms disappear and the patient requests discharge. Why should the nurse emphasize that it is important for the patient to be treated before leaving?

a. The patient has probably experienced an asymptomatic lacunar stroke.
b. The symptoms are likely to return and progress to worsening neurological deficit in the next 24 hours.
c. Neurologic deficits that are transient occur most often as a result of small hemorrhages that clot off.
d. The patient has probably experienced a transient ischemic attack (TIA), which is a sign of progressive cerebrovascular disease.

Answer 3

d. The patient has probably experienced a transient ischemic attack (TIA), which is a sign of progressive cerebrovascular disease.

Question 4

What are the characteristics of a stroke caused by an intracerebral hemorrhage (select all that apply)?

a. Carries a poor prognosis
b. Caused by rupture of a vessel
c. Strong association with hypertension
d. Commonly occurs during or after sleep
e. Creates a mass that compresses the brain

Answer 4

a. Carries a poor prognosis
b. Caused by rupture of a vessel
e. Creates a mass that compresses the brain

Strokes from intracerebral hemorrhage have a poor prognosis, are caused by the rupture of a blood vessel, are frequently atherosclerotic, and create a mass that compresses the brain. Thrombotic strokes are related to hypertension and occur during sleep or after sleep.

Question 5

Which type of stroke is associated with endocardial disorders, has a rapid onset, and is unrelated to activity?

a. Embolic
b. Thrombotic
c. Intracerebral hemorrhage
d. Subarachnoid hemorrhage

Answer 5

a. Embolic

Embolic strokes are associated with endocardial disorders such as atrial fibrillation, have a rapid onset, and are unrelated to activity.

Question 6

Indicate whether the following manifestations of a stroke are more likely to occur with right brain damage (R) or left brain damage (L).
___ a. Aphasia
___ b. Impaired judgment
___ c. Quick, impulsive behavior
___ d. Inability to remember words
___ e. Left homonymous hemianopsia
___ f. Neglect of the left side of the body
___ g. Hemiplegia of the right side of the body

Answer 6

L a. Aphasia
R b. Impaired judgment
R c. Quick, impulsive behavior
L d. Inability to remember words
R e. Left homonymous hemianopsia
R f. Neglect of the left side of the body
L g. Hemiplegia of the right side of the body

Question 7

The patient has a lack of comprehension of both verbal and written language. Which type of communication difficulty does this patient have?

a. Dysarthria
b. Fluent dysphasia
c. Receptive aphasia
d. Expressive aphasia

Answer 7

c. Receptive aphasia

Receptive aphasia is the lack of comprehension of both verbal and written language. Dysarthia is a disturbance in muscular control of speech. In fluent dysphagia speech is present but contains little meaningful communication. Expressive aphasia is the loss of the production of language.

Question 8

A patient is admitted to the hospital with a left hemiplegia. To determine the size and location and to ascertain whether a stroke is ischemic or hemorrhagic, the nurse anticipates that the health care provider will request a

a. lumbar puncture.
b. cerebral arteriogram.
c. magnetic resonance imaging (MRI).
d. computed tomography (CT) scan with contrast.

Answer 8

c. magnetic resonance imaging (MRI).

MRI could be used to rapidly distinguish between ischemic and hemorrhagic stroke and determine the size and location of the lesion. A noncontrast CT scan could also be used. Lumbar punctures are not performed routinely because of the chance of ICP causing herniation. Cerebral arteriograms are invasive and may dislodge an embolism or cause further hemorrhage. They are performed only when no other test can provide the needed information.

Question 9

A carotid endarterectomy is being considered as treatment for a patient who has had several TIAs. What should the nurse explain to the patient about this surgery?

a. It involves intracranial surgery to join a superficial extracranial artery to an intracranial artery.
b. It is used to restore blood circulation to the brain following an obstruction of a cerebral artery.
c. It involves removing an atherosclerotic plaque in the carotid artery to prevent an impending stroke.
d. It is used to open a stenosis in a carotid artery with a balloon and stent to restore cerebral circulation.

Answer 9

c. It involves removing an atherosclerotic plaque in the carotid artery to prevent an impending stroke.

A carotid endarterectomy is the removal of an atherosclerotic plaque in the carotid arteries that may impair circulation enough to cause a stroke.

Question 10

What primarily determines the neurologic functions that are affected by a stroke?

a. The amount of tissue area involved
b. The rapidity of the onset of symptoms
c. The brain area perfused by the affected artery
d. The presence of absence of collateral circulation

Answer 10

c. The brain area perfused by the affected artery

Clinical manifestations of altered neurologic function differ, depending primarily on the specific cerebral artery involved and the area of the brain that is perfused by the artery. The degree of impairment depends on rapidity of onset, the size of the lesion, and the presence of collateral circulation.

Question 11

The incidence of ischemic stroke in patients with TIAs and other risk factors is reduced with the administration of which medication?

a. Furosemide (Lasix)
b. Lovastatin (Mevacor)
c. Daily low-dose aspirin
d. Nimodipine (Nimotop)

Answer 11

c. Daily low-dose aspirin

Question 12

What is the priority intervention in the emergency department for the patient with a stroke?

a. Intravenous fluid replacement
b. Administration of osmotic diuretics to reduce cerebral edema
c. Initiation of hypothermia to decrease the oxygen needs of the brain
d. Maintenance of respiratory function with patent airway and oxygen administration

Answer 12

d. Maintenance of respiratory function with patent airway and oxygen administration

Question 13

During the acute phase of a stroke, the nurse assesses the patient’s vital signs and neurologic status every 4 hours. What is a cardiovascular sign that the nurse would see as the body attempts to increase blood flow?

a. Hypertension
b. Fluid overload
c. Cardiac dysrhythmias
d. S3 and S4 heart sounds

Answer 13

a. Hypertension

Question 14

During the secondary assessment of the patient with a stroke, what all should be included (select all that apply)?

a. Gaze
b. Sensation
c. Facial palsy
d. Proprioception
e. Current medications
f. Distal motor function

Answer 14

a. Gaze
b. Sensation
c. Facial palsy
d. Proprioception
f. Distal motor function

Question 15

A diagnosis of a ruptured cerebral aneurysm has been made in a patient with manifestations of a stroke. The nurse anticipates which treatment option that would be considered for the patient?

a. Hyperventilation therapy
b. Surgical clipping of the aneurysm
c. Administration of hyperosmotic agents
d. Administration of thrombolytic therapy

Answer 15

b. Surgical clipping of the aneurysm

Question 16

What is a nursing intervention that is indicated for the patient with hemiplegia?

a. The use of a footboard to prevent plantar flexion
b. Immobilization of the affected arm against the chest with a sling
c. Positioning the patient in bed with each joint lower than the joint proximal to it
d. Having the patient perform passive range of motion (ROM) of the affected limb with the unaffected limb

Answer 16

d. Having the patient perform passive range of motion (ROM) of the affected limb with the unaffected limb

Question 17

The factor related to cerebral blood flow that most often determines the extent of cerebral damage from a stroke is the

a. amount of cardiac output.
b. oxygen content of the blood.
c. degree of collateral circulation.
d. level of carbon dioxide in the blood.

Answer 17

c. degree of collateral circulation.

The extent of the stroke depends on the rapidity of onset, size of the lesion, and presence of collateral circulation.

Question 18

Information provided by the patient that would help differentiate a hemorrhagic stroke from a thrombotic stroke includes

a. sensory disturbance.
b. a history of hypertension.
c. presence of motor weakness.
d. sudden onset of severe headache.

Answer 18

d. sudden onset of severe headache.

A hemorrhagic stroke usually causes a sudden onset of symptoms, which include neurologic deficits, headache, nausea, vomiting, decreased level of consciousness, and hypertension. Ischemic stroke symptoms may progress in the first 72 hours as infarction and cerebral edema increase.

Question 19

A patient’s wife asks the nurse why her husband did not receive the clot busting medication (tissue plasminogen activator [tPA] she has been reading about. Her husband is diagnosed with a hemorrhagic stroke. What is the best response by the nurse to the patient’s wife?

a. “He didn’t arrive within the timeframe for that therapy.”
b. “Not everyone is eligible for this drug. Has he had surgery lately?”
c. “You should discuss the treatment of your husband with his doctor.”
d. “The medication you are talking about dissolves clots and could cause more bleeding in your husband’s brain.”

Answer 19

d. “The medication you are talking about dissolves clots and could cause more bleeding in your husband’s brain.”

Question 20

In promoting health maintenance for prevention of strokes, the nurse understands that the highest risk for the most common type of stroke is present in which people?

a. African Americans
b. Women who smoke
c. Individuals with hypertension and diabetes
d. Those who are obese with high dietary fat intake

Answer 20

c. Individuals with hypertension and diabetes

Question 21

While performing health screenings at a health fair, the nurse identifies which of the following individuals at greatest risk for experiencing a stroke?

1. A 46 year old white female with hypertension (HTN) and oral contraceptive use for 10 years.
2. A 58 year old white male salesman who has total cholesterol level of 285 mg/dL.
3. A 42 year old African American female with diabetes mellitus who has smoked for 30 years.
4. A 64 year old African American male with hypertension (HTN) who is 35 pounds overweight

Answer 21

4. A 64 year old African American male with hypertension (HTN) who is 35 pounds overweight

Question 22

The nurse would expect to find which of the following clinical manifestations in a patient admitted with a left-brain stroke?

1. Impulsivity
2. Impaired speech
3. Left-side neglect
4. Short attention span

Answer 22

2. Impaired speech

Question 23

A 70-year-old female client with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first?

1. Monitor the blood pressure.
2. Send the client for a computed tomography (CT) scan.
3. Check the respiratory rate and effort.
4. Assess the Glasgow Coma Scale score.

Answer 23

3. Check the respiratory rate and effort.

Question 24

A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing prevention is priority?

1. Prepare to administer recombinant tissue plasminogen activator (rt-PA).
2. Discuss the precipitating factors that caused the symptoms.
3. Schedule for a STAT computed tomography (CT) scan of the head.
4. Notify the speech pathologist for an emergency consult.

Answer 24

3. Schedule for a STAT computed tomography (CT) scan of the head.

A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. If a CVA is diagnosed, the CT scan can determine if it is a hemorrhagic or ischemic accident and guide treatment.

Question 25

The nurse is assessing a client experiencing motor loss as a result of a left-sided cerebrovascular accident (CVA). Which clinical manifestations would the nurse document?

1. Hemiparesis of the client’s left arm and apraxia.
2. Paralysis of the right side of the body and ataxia.
3. Homonymous hemianopsia and diplopia.
4. Impulsive behavior and hostility toward family.

Answer 25

2. Paralysis of the right side of the body and ataxia.

The most common motor dysfunction of a CVA is paralysis of one side of the body, hemiplegia; in this case with a left-sided CVA, the paralysis would affect the right side. Ataxia is an impaired ability to coordinate movement.

Question 26

Which client would the nurse identify as being most at risk for experiencing a CVA?

1. A 55-year-old African American male.
2. An 84-year-old Japanese female.
3. A 67-year-old Caucasian male.
4. A 39-year-old pregnant female.

Answer 26

1. A 55-year-old African American male.

African Americans have twice the rate of CVAs as Caucasians and men have a higher incidence than women; African Americans suffer more extensive damage from a CVA than do people of other cultural groups.

Question 27

The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge?

1. An oral anticoagulant medication.
2. A beta blocker medication.
3. An anti-hyperuricemic medication.
4. A thrombolytic medication.

Answer 27

1. An oral anticoagulant medication.

The nurse would anticipate an oral anticoagulant, warfarin (Coumadin), to be prescribed to help prevent thrombi formation in the atria secondary to atrial fibrillation. The thrombi can become embolic and may cause a TIA or CVA (stroke).

Question 28

Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke?

1. A blood glucose level of 480 mg/dL.
2. A right-sided carotid bruit.
3. A blood pressure of 220/120 mm Hg.
4. The presence of bronchogenic carcinoma.

Answer 28

3. A blood pressure of 220/120 mm Hg.

Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a ruptured blood vessel inside the cranium.

Question 29

The 85-year-old client diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first?

1. Administer a nonnarcotic analgesic.
2. Prepare for STAT magnetic resonance imaging (MRI).
3. Start an intravenous infusion with D5W at 100 mL/hr.
4. Complete a neurological assessment.

Answer 29

4. Complete a neurological assessment.

The nurse must complete a neurological assessment to help determine the cause of the headache before taking any further action.

Question 30

A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement?

1. Administer a stool softener b.i.d.
2. Encourage the client to cough hourly.
3. Monitor the neurological status every shift.
4. Maintain the dopamine drip to keep BP at 160/90.

Answer 30

1. Administer a stool softener b.i.d.

The client is at risk for increased intracranial pressure whenever performing the Valsalva maneuver, which will occur when straining during defecation. Therefore, stool softeners would be appropriate.

Question 31

Which modifiable risk factors for stroke would be most important for the nurse to include when planning a community education program?

a. Hypertension
b. Hyperlipidemia
c. Alcohol consumption
d. Oral contraceptive use

Answer 31

a. Hypertension

Hypertension is the single most important modifiable risk factor, but it is still often undetected and inadequately treated. The public is often more aware of hyperlipidemia and oral contraceptive use as risk factors for stroke. Alcohol is also a modifiable risk factor.

Question 32

The nurse is discharging a patient admitted with a transient ischemic attack (TIA). For which medications might the nurse expect to provide discharge instructions (select all that apply)?
A. Clopidogrel (Plavix) 
B. Enoxaparin (Lovenox) 
C. Dipyridamole (Persantine) 
D. Enteric-coated aspirin (Ecotrin) 
E. Tissue plasminogen activator (tPA)

Answer 32

A. Clopidogrel (Plavix)
C. Dipyridamole (Persantine)
D. Enteric-coated aspirin (Ecotrin)

Aspirin is the most frequently used antiplatelet agent. Other drugs to prevent clot formation include clopidogrel (Plavix), dipyridamole (Persantine), ticlopidine (Ticlid), combined dipyridamole and aspirin (Aggrenox), and anticoagulant drugs, such as oral warfarin (Coumadin). Tissue plasminogen activator is a fibrinolytic medication used to treat ischemic stroke not prevent TIAs or strokes.

Question 33

Computed tomography (CT) of a 68-year-old male patient’s head reveals that he has experienced a hemorrhagic stroke. What is the priority nursing intervention in the emergency department?

a. Maintenance of the patient’s airway
b. Positioning to promote cerebral perfusion
c. Control of fluid and electrolyte imbalances
d. Administration of tissue plasminogen activator (tPA)

Answer 33

a. Maintenance of the patient’s airway

Maintenance of a patent airway is the priority in the acute care of a patient with a hemorrhagic stroke. It supersedes the importance of fluid and electrolyte imbalance and positioning. tPA is contraindicated in hemorrhagic stroke.

Question 34

Which sensory-perceptual deficit is associated with left-sided stroke (right hemiplegia)?

a. Overestimation of physical abilities
b. Difficulty judging position and distance
c. Slow and possibly fearful performance of tasks
d. Impulsivity and impatience at performing tasks

Answer 34

c. Slow and possibly fearful performance of tasks

Patients with a left-sided stroke (right hemiplegia) commonly are slower in organization and performance of tasks and may have a fearful, anxious response to a stroke. Overconfidence, spatial disorientation, and impulsivity are more commonly associated with a right-sided stroke.

Question 35

The female patient has been brought to the ED with a sudden onset of a severe headache that is different from any other headache she has had previously. When considering the possibility of a stroke, which type of stroke should the nurse know is most likely occurring?

a. TIA
b. Embolic stroke
c. Thrombotic stroke
d. Subarachnoid hemorrhage

Answer 35

d. Subarachnoid hemorrhage

Headache is common in a patient who has a subarachnoid hemorrhage or an intracerebral hemorrhage. A TIA is a transient loss of neurologic function usually without a headache. A headache may occur with an ischemic embolic stroke, but severe neurologic deficits are the initial symptoms. The ischemic thrombotic stroke manifestations progress in the first 72 hours as infarction and cerebral edema increase.

Question 36

The patient with diabetes mellitus has had a right-sided stroke. Which nursing intervention should the nurse plan to provide for this patient related to expected manifestations of this stroke?

a. Safety measures
b. Patience with communication
c. Mobility assistance on the right side
d. Place food in the left side of patient’s mouth.

Answer 36

a. Safety measures

A patient with a right-sided stroke has spatial-perceptual deficits, tends to minimize problems, has a short attention span, is impulsive, and may have impaired judgment. Safety is the biggest concern for this patient. Hemiplegia occurs on the left side of this patient’s body. The patient with a left-sided stroke has hemiplegia on the right, is more likely to have communication problems, and needs mobility assistance on the right side with food placed on the left side if the patient needs to be fed after a swallow evaluation has taken place.

Question 37

The client diagnosed with a right-sided cerebrovascular accident (CVA) is admitted to the rehabilitation unit. Which priority intervention should be included in the nursing care plan?

1. Position the client to prevent shoulder adduction.
2. Set up the client’s tray during meals.
3. Turn and reposition the client every shift.
4. Refer the client to an occupational therapist.

Answer 37

1. Position the client to prevent shoulder adduction.

Placing a small pillow under the shoulder will prevent the shoulder from adducting toward the chest and developing a contracture. This is priority because it is a physiological need.