Deck 18: Acute Stroke Injury

Question 1

The nurse is assessing a newly admitted older patient for modifiable risk factors for stroke development.The nurse would include teaching about which findings? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

A)Blood pressure is consistently above 95 diastolic.
B)The patient has had two recent hospital admissions to treat dehydration.
C)The patient reports drinking a glass of wine with dinner every evening.
D)The patient uses smokeless tobacco.
E)Testing has previously indicated the patient has hypercholesterolemia.

Answer 1

Blood pressure is consistently above 95 diastolic.
The patient has had two recent hospital admissions to treat dehydration.
Testing has previously indicated the patient has hypercholesterolemia.

Question 2

When developing a teaching plan for a patient who had an embolic stroke,the nurse considers which history as a significant risk factor?

A)Hypertension
B)Use of anticoagulants
C)History of atherosclerosis of cerebral arteries
D)Atrial fibrillation

Answer 2

Atrial fibrillation

Question 3

A patient who has been admitted with symptoms of stroke is to have a CT scan.What rationale for this testing would the nurse provide to the patient and family?

A)CT scans are used to determine the effectiveness of the cerebral circulation to perfuse all areas of the brain.
B)The CT scan will evaluate how much brain swelling is associated with this stroke.
C)The CT scan will pinpoint the exact area of the brain affected by the stroke.
D)The CT scan can guide treatment by differentiating hemorrhagic from ischemic causes of the stroke.

Answer 3

The CT scan can guide treatment by differentiating hemorrhagic from ischemic causes of the stroke.

Question 4

The nurse is triaging a patient who just presented to the emergency department.Which cluster of assessment findings would the nurse evaluate as indicating the greatest possibility that this patient is having a stroke?

A)Radicular pain,decreased deep tendon reflexes,loss of bladder control
B)Difficulty with balance,hemianopsia,hemiparesis
C)Dystonia,dysphagia,dysarthria
D)Paresthesia,priapism,loss of reflexes

Question 5

When planning nursing care for a patient with a stroke,the nurse should consider which primary goal of medical management?

A)Restoration of cerebral blood flow and limiting the size of the infarcted area of the brain
B)Keeping the blood pressure under control pharmacologically
C)Transferring the patient for rehabilitation as soon as medically stable
D)Reestablishing blood flow to the infarcted area surgically

Question 6

The nurse is instructing a patient on stroke prevention.Which patient statement would the nurse evaluate as indicating understanding of the presence of a nonmodifiable risk factor for stroke development?

A)"I have hypertension just like my mom and her family."
B)"Lots of people of my ethnicity suffer strokes."
C)"I have tried several times to quit smoking,but I just can't seem to do it."
D)"It is going to be hard to give up eating red meat and my favorite family meals just to lower my cholesterol."

Question 7

A patient is diagnosed with bleeding into the cerebellum.The nurse would prepare this patient for which medical intervention?

A)Angioplasty
B)Immediate surgery to remove the blood from the cerebellum
C)Stent placement
D)Aggressive diuretic therapy to dehydrate cerebral tissues

Question 8

Which nursing interventions are indicated when providing care for a patient recovering from right carotid endarterectomy? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

A)Position the patient supine on the left side.
B)Teach the patient to hold his head for support when changing positions.
C)Conduct frequent assessments for facial drooping or tongue deviation.
D)Monitor blood pressure level frequently.
E)Perform frequent tracheostomy care.

Question 9

A patient is receiving tissue plasminogen activator (tPA)for the treatment of an ischemic stroke.Which nursing interventions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

A)Insert a nasogastric tube for nutritional support.
B)Monitor for renal stone formation.
C)Monitor for deterioration of neurological status.
D)Reposition every 15 minutes.

Question 10

A patient comes into the emergency department with complaints of partial loss of vision in one eye,numbness and tingling of the arm and leg,and dizziness.Which additional information should the nurse initially seek from the patient?

A)If the patient has high blood pressure
B)If the symptoms are still present
C)If this is a recurrent problem
D)If the patient fell

Question 11

A patient with cerebral infarction is experiencing an acceleration of symptoms indicating death of cerebral tissue.The nurse would explain this acceleration as due to which pathophysiology?

A)Increased concentration of sodium,chloride,and calcium in the brain cells
B)Reduced ability of the macrophages to reach the site of injury
C)Reduced concentration of magnesium and phosphorus in the brain cells
D)Increased concentration of potassium in the brain cells

Question 12

Which assessment finding increases the concern that a patient with a cerebral vascular accident would aspirate?

A)Eating only foods on one side of the tray
B)Refusal to allow the nurse to assist with feeding
C)Absence of interest in eating or drinking
D)Continuous clearing of the throat

Question 13

The nurse is planning care for a patient with a thrombotic stroke in the distribution of the right middle cerebral artery.Which patient problem is the priority for care in the acute phase of this disease process?

A)Nutrition will not be adequate due to dysphagia.
B)Patient will require total care due to paralysis.
C)Brain damage will occur because the adaptive capacity of the brain is altered.
D)Circulation of the brain is no longer adequate for aerobic metabolism.

Question 14

A patient with spasticity of the upper extremity after a stroke asks why a sling is not used to support the arm.Which rationale should the nurse provide?

A)The use of a sling will reinforce the spasticity and may promote a contracture.
B)A sling will alter your center of balance when standing.
C)The presence of a sling will make it difficult for you to assume responsibility for activities of daily living like dressing.
D)You will not be able to participate in therapy if you get accustomed to your arm being in a sling.

Question 15

A patient is recovering from surgery to clip an aneurysm.The nurse would anticipate managing which interventions to help prevent cerebral vasospasm?

A)Infusion of packed red blood cells
B)Diuretic therapy
C)Oral fluid restriction
D)Intravenous fluid augmentation

Question 16

Which goal would the nurse rank as priority for a patient with stroke-related sensory perception alterations?

A)The patient and caregivers will discuss methods to avoid hazards in the environment.
B)The patient will work to increase perception of sensations.
C)The patient will not experience further loss of sensation.
D)The patient will understand the risk of injury related to decreased sensation.

Question 17

Diagnostic testing reveals that a patient has areas of cerebral focal infarctions.The nurse plans care with the realization that which outcome is likely?

A)The patient will likely deteriorate into multiple system organ failure.
B)These areas of ischemia will likely extend into the brainstem.
C)The patient's symptoms may resolve with treatment.
D)The patient's symptoms will progress rapidly.

Question 18

A patient,admitted with syncope,is diagnosed with an 80% stenosis of the left carotid artery.In addition to assessing the patient's speech,the nurse should focus the assessment on the presence or development of which other findings?

A)Vertigo and cranial nerve palsies
B)Monocular blindness and left-sided sensory loss
C)Double vision and ataxia
D)Right-sided hemineglect,sensory and motor loss

Question 19

The nurse is providing community education regarding stroke.Which information should be included? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

A)Stroke is caused by interruption of blood flow to the brain.
B)Stroke is the fifth-leading cause of death in the United States.
C)Stroke usually occurs simultaneously with myocardial infarction (MI).
D)Rapid recognition of stroke symptoms can help decrease poor outcomes.
E)Stroke causes neurological defects.

Question 20

A patient had a stroke that resulted in Broca's aphasia.What instructions should the nurse provide when teaching the family how to communicate with this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

A)Speak slowly and loudly to the patient.
B)Use paper and pencil for all communication.
C)Ask the patient "yes-no" questions.
D)Anticipate the patient's answers and finish questions and sentences.
E)Give the patient time to search for words.