Neuro NCLEX Questions

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Chapter 58: Stroke

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NUR 21

13 terms chr 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 request discharge. The nurse stresses that it is important for the patient to be evaluated primarily because the patient has probably experienced a; a.) Transient ischemic attack b.) Ischemic stroke c.) Hemorrhagic stroke d.) MI a.) Transient ischemic stroke

Rationale:

The patient has probably experienced a transient ischemic attack (TIA), which is a sign of progressive cerebral vascular disease- (A TIA is a temporary focal loss of neurologic function caused by ischemia of an area of the brain, usually lasting only about 3 hours. TIAs may be due to microemboli from heart disease or carotid or cerebral thrombi and are a warning of progressive disease. Evaluation is necessary to determine the cause of the neurologic deficit and provide prophylactic treatment if possible.) Aspirin is ordered for a patient who is admitted with a possible stroke. Which information obtained during the admission assessment indicates that the nurse should consult with the health care provider before giving the aspirin?

• The patient has dysphasia.
• The patient has atrial fibrillation.
• The patient states, "My symptoms started with a terrible

headache."

• The patient has a history of brief episodes of right-

sided hemiplegia.

• The patient states, "My symptoms started with a terrible headache."

Rationale:

A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack (TIA) are not contraindications to aspirin use, so the nurse can administer the aspirin.

A patient with a stroke experiences right-sided arm and leg paralysis and facial drooping on the right side. When admitting the patient, which clinical manifestation will the nurse expect to find?

• Impulsive behavior
• Right-sided neglect
• Hyperactive left-sided reflexes
• Difficulty in understanding commands
• Difficulty in understanding commands

Rationale:

Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with comprehension and use of language. The left-side reflexes are likely to be intact.Impulsive behavior and neglect are more likely with a right-side stroke.A patient with a history of several transient ischemic attacks (TIAs) arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. The nurse anticipates the need to prepare the patient for

• surgical endarterectomy.
• transluminal angioplasty.
• intravenous heparin administration.
• tissue plasminogen activator (tPA) infusion.
• tissue plasminogen activator (tPA) infusion.

Rationale:

The patient's history and clinical manifestations suggest an acute ischemic stroke and a patient who is seen within 4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is having an acute ischemic stroke.When caring for a patient with left-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care during the acute period of the stroke?

• Apply an eye patch to the left eye.
• Approach the patient from the left side.
• Place objects needed for activities of daily living on

the patient's right side.

• Reassure the patient that the visual deficit will resolve

as the stroke progresses.

• Place objects needed for activities of daily living on the patient's right side.

Rationale:

During the acute period, the nurse should place objects on the patient's unaffected side. Since there is a visual defect in the left half of each eye, an eye patch is not appropriate. The patient should be approached from the right side.The visual deficit may not resolve, although the patient can learn to compensate for the defect.A 32-year-old patient has a stroke resulting from a ruptured aneurysm and subarachnoid hemorrhage.Which intervention will be included in the care plan?

• Applying intermittent pneumatic compression

stockings

• Assisting to dangle on edge of bed and assess for

dizziness

• Encouraging patient to cough and deep breathe every
• hours
• Inserting an oropharyngeal airway to prevent airway

obstruction

• Applying intermittent pneumatic compression stockings

Rationale:

The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thromboemboism (VTE). Activities such as coughing and sitting up that might increase intracranial pressure (ICP) or decrease cerebral blood flow are avoided.Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate.

A patient with sudden-onset right-sided weakness has a CT scan and is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider?

• The patient's speech is difficult to understand.
• The patient's blood pressure is 144/90 mm Hg.
• The patient takes a diuretic because of a history of

hypertension.

• The patient has atrial fibrillation and takes warfarin

(Coumadin).

• The patient has atrial fibrillation and takes warfarin (Coumadin).

Rationale:

The use of warfarin will have contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patient's care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated.A patient with right-sided weakness that started 90 minutes earlier is admitted to the emergency department and all these diagnostic tests are ordered. Which test should be done first?

• Electrocardiogram (ECG)
• Complete blood count (CBC)
• Chest radiograph (Chest x-ray)
• Noncontrast computed tomography (CT) scan
• Noncontrast computed tomography (CT) scan

Rationale:

Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 4.5 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the smaller the area of brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.A patient who has had a subarachnoid hemorrhage is being cared for in the intensive care unit. Which information about the patient is most important to communicate to the health care provider?

• The patient's blood pressure is 90/50 mm Hg.
• The patient complains about having a stiff neck.
• The cerebrospinal fluid (CSF) report shows red blood

cells (RBCs).

• The patient complains of an ongoing severe headache.
• The patient's blood pressure is 90/50 mm Hg.

Rationale:

To prevent cerebral vasospasm and maintain cerebral perfusion, blood pressure needs to be maintained at a level higher than 90 mm Hg systolic after a subarachnoid hemorrhage. A low BP or drop in BP indicates a need to administer fluids and/or vasopressors to increase the BP. An ongoing headache, RBCs in the CSF, and a stiff neck are all typical clinical manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the health care provider.Damage to which area of the brain results in receptive aphasia?a.) Temporal lobe b.) Parietal lobe c.) Frontal lobe d.) Occipital lobe a.) Temporal lobe The nurse giving discharge teaching for a client receiving

carbamazepine (Tegretol) should include:

a.) Monitor blood glucose, and report decreased levels.b.) Expect a discoloration of the contact lenses.c.) Report unusual bleeding or bruises to the health care provider immediately.d.) Expect an orange discoloration of urine.c.) Report unusual bleeding or bruises to the health care provider immediately.

Rationale:

Carbamazepine affects vitamin K metabolism, and can lead to blood dyscraisias and bleeding. It does not significantly lower blood sugar or change the color of body fluids.

A client receiving digoxin (Lanoxin) therapy is being treated for status epilepticus with diazepam (Valium). The

nurse places priority on:

a.) Holding the digoxin until the seizure has subsided.b.) Keeping the client in a high Fowler's position.c.) Monitoring the client for nausea and GI cramping.d.) Instructing the client to eat foods high in potassium.c.) Monitoring the client for nausea and GI cramping.

Rationale:

Valium is a benzodiazepine, which can potentate the action of digoxin and raise blood levels. Nausea, vomiting, GI cramping, blurred vision, and bigeminy are signs of digoxin toxicity. The digoxin should not be held unless symptoms of toxicity are seen. Positioning should protect the client from injury during the seizure-most likely recumbent and on the side, if possible. Potassium is not indicated.A client asks if convulsions and seizures are the same. The

nurse's response is based on the knowledge that:

a.) The terms can be used interchangeably.b.) Convulsions always involve violent skeletal muscle activity.c.) Seizures involve muscle spasms on one side only.d.) Seizure activity is more harmful than are convulsions.b.) Convulsions always involve violent skeletal muscle activity.

Rationale:

Convulsions specifically refer to involuntary, violent spasms of the large muscles of the face, neck, arms, and legs. Seizure activity does not always involve these characteristics.The most important preventative measure for hemorrhagic stroke is?a.) Smoking cessation b.) Blood pressure control c.) Maintaining a healthy weight d.) Management of DM b.) Blood pressure control While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure.Which action should the nurse take?a.) Insert an oral airway during the seizure to maintain a patent airway.b.) Restrain the patient's arms and legs to prevent injury during the seizure.c.) Observe and record the details of the seizure and postictal state.d.) Avoid touching the patient to prevent further nervous system stimulation.c.) Observe and record the details of the seizure and postictal state.

Rationale:

Because the diagnosis and treatment of seizures frequently are based on the description of the seizure, recording the length and details of the seizure is important. Insertion of an oral airway and restraining the patient during the seizure are contraindicated. The nurse may need to move the patient to decrease the risk of injury during the seizure.A patient reports feeling numbness and tingling of the left arm before experiencing a tonic-clonic seizure. The nurse determines that this history is consistent with what type of seizure?a.) Focal b.) Atonic c.) Absence d.) Myoclonic a.) Focal

Rationale:

The initial symptoms of a focal seizure involve clinical manifestations that are localized to a particular part of the body or brain. Symptoms of an absence seizure are staring and a brief loss of consciousness. In an atonic seizure, the patient loses muscle tone and (typically) falls to the ground. Myoclonic seizures are characterized by a sudden jerk of the body or extremities.