Cerebrovascular Accident Stroke - Practice Questions

Cerebrovascular Accident (Stroke) - Practice Questions 5.0 (2 reviews) Students also studied Terms in this set (12) Science MedicineNeurology Save CVA 110 terms inchristicanPreview Spinal Cord Injury NCLEX 26 terms ET0003Preview Cerebrovascular Accident (Stroke) P...12 terms hann_dahlPreview CVA stu 15 terms lizz 3A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority?

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

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.2The 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?

• Hemiparesis of the client's left arm and apraxia.
• Paralysis of the right side of the body and ataxia.
• Homonymous hemianopsia and diplopia.
• Impulsive behavior and hostility toward family.

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 move

1Which client would the nurse identify as being most at risk for experiencing a CVA?

• A 55-year-old African American male.
• An 84-year-old Japanese female.
• A 67-year-old Caucasian male.
• A 39-year-old pregnant female.

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.1, 3The client diagnosed with a right-sided cerebrovascular accident is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan?Select all that apply.

• Position the client to prevent shoulder adduction.
• Turn and reposition the client every shift.
• Encourage the client to move the affected side.
• Perform quadriceps exercises three (3) times a day.
• Instruct the client to hold the fingers in a fist.
• Placing a small pillow under the shoulder will prevent the shoulder from

adducting toward the chest and developing a contracture.

• The client should not ignore the paralyzed side, and the nurse must encourage

the client to move it as much as possible; a written schedule may assist the client in exercising.4The nurse is planning care for a client experiencing agnosia secondary to a cerebrovascular accident. Which collaborative intervention will be included in the plan of care?

• Observe the client swallowing for possible aspiration.
• Position the client in a semi-Fowler's position when sleeping.
• Place a suction setup at the client's bedside during meals.
• Refer the client to an occupational therapist for evaluation.

A collaborative intervention is an intervention in which another health-care discipline—in this case, occupational therapy—is used in the care of the client.3The nurse and an unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene?

• The assistant places a gait belt around the client's waist prior to ambulating.
• The assistant places the client on the back with the client's head to the side.
• The assistant places a hand under the client's right axilla to move up in bed.
• The assistant praises the client for attempting to perform ADLs independently.

This action is inappropriate and would require intervention by the nurse because pulling on a flaccid shoulder joint could cause shoulder dislocation; the client should be pulled up by placing the arm underneath the back or using a lift sheet.

1The 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?

• An oral anticoagulant medication.
• A beta blocker medication.
• An anti-hyperuricemic medication.
• A thrombolytic 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).4The client has been diagnosed with a cerebrovascular accident (stroke). The client's wife is concerned about her husband's generalized weakness. Which home modification should the nurse suggest to the wife prior to discharge?

• Obtain a rubber mat to place under the dinner plate.
• Purchase a long-handled bath sponge for showering.
• Purchase clothes with Velcro closure devices.
• Obtain a raised toilet seat for the client's bathroom.

Raising the toilet seat is modifying the home and addresses the client's weakness in being able to sit down and get up without straining muscles or requiring lifting assistance from the wife.2The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the plan of care?

• Potential for injury.
• Powerlessness.
• Disturbed thought processes.
• Sexual dysfunction.

Expressive aphasia means that the client cannot communicate thoughts but understands what is being communicated; this leads to frustration, anger, depression, and the inability to verbalize needs, which, in turn, causes the client to have a lack of control and feel powerless 3Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke?

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

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

4The 85-year-old client diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first?

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

The nurse must complete a neurological assessment to help determine the cause of the headache before taking any further action.1A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement?

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

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.