Stroke Practice Questions Test 3, Fall 2020

Stroke Practice Questions (Test #3, Fall 2020) Leave the first rating Students also studied Terms in this set (34) Science MedicineNeurology Save Stroke MCQ 22 terms chungs91Preview Stroke Questions 52 terms corrine_riggins Preview Stroke - Practice Questions 74 terms josephcafPreview Head In 37 terms LeM A 78-year-old client is admitted to the emergency department (ED) 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.3

• The drug rt-PA may be administered, but a cerebrovascular accident (CVA) must

be verified by diagnostic tests prior to administering it. The drug rt-PA helps dissolve a blood clot, and it may be administered if an ischemic CVA is verified; rt- PA is not given if the client is experiencing a hemorrhagic stroke.

• Teaching is important to help prevent another CVA, but it is not the priority

intervention on admission to the emergency department. Slurred speech indicates problems that may interfere with teaching.

• 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 an ischemic accident and guide treatment.

• The client may be referred for speech deficits and/or swallowing difficulty, but

referrals are not the priority in the emergency department.TEST TAKING HINT: When "priority" is used in the stem, all answer options may be appropriate for the client situation, but only one option is the priority. The client must have a documented diagnosis before treatment is started

The nurse is assessing a client experiencing motor loss as a result of a left-sided cerebrovascular accident (CVA).Which clinical manifestation 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

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• A left-sided cerebrovascular accident (CVA) will result in right-sided motor

deficits; hemiparesis is weakness of one-half of the body, not just the upper extremity. Apraxia, the inability to perform a previously learned task, is a communication loss, not a motor loss.

• 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.

• Homonymous hemianopsia (loss of half of the visual field of each eye) and

diplopia (double vision) are visual field deficits that a client with a CVA may experience, but they are not motor losses.

• Personality disorders occur in clients with a right-sided CVA and are cognitive

deficits; hostility is an emotional deficit.

TEST TAKING HINT: Be sure to always notice adjectives describing something. In

this case, "left-sided" describes the type of CVA. Also be sure to identify exactly what the question is asking—in this case, about "motor loss," which will help rule out many of the possible answer options.Which client would the nurse identify as being most at risk for experiencing a cerebrovascular accident (CVA)?

• A 55-year-old African American male.
• An 84-year-old Japanese female.
• A 67-year-old Caucasian male. 4. A 39-year-old

pregnant female.1

• African Americans have twice the rate of CVAs as Caucasians and men have a

higher incidence than women; African Americans also suffer more extensive damage from a CVA than do people of other cultural groups.

• Females are less likely to have a CVA than males, but advanced age does

increase the risk for CVA. The Asian population has a lower risk, possibly as a result of their relatively high intake of omega-3 fatty acids, antioxidants found in fish.

• Caucasians have a lower risk of CVA than do African Americans, Hispanics, and

Native Pacific Islanders.

• Pregnancy is a minimal risk for having a CVA.

TEST TAKING HINT: Note the age of the client if this information is given, but take this information in context with the additional information provided in the answer options. The 84-year-old may appear to be the best answer but not if the client is a female and Asian, which rules out this option for the client most at risk

The 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.

1,3

• Placing a small pillow under the shoulder will prevent the shoulder from

adducting toward the chest and developing a contracture.

• The client should be repositioned at least every two (2) hours to prevent

contractures, pneumonia, skin breakdown, and other complications of immobility.

• 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.

• These exercises are recommended, but they must be done at least five (5) times

a day for 10 minutes to help strengthen the muscles for walking.

• The fingers are positioned so that they are barely flexed to help prevent

contracture of the hand.TEST TAKING HINT: Be sure to look at the intervals of time for any intervention; note that "every shift" and "three (3) times a day" are not appropriate time intervals for this client. Because this is a "select all that apply" question, the test taker must read each answer option and decide if it is correct; one will not eliminate another The 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.4

• Agnosia is the failure to recognize familiar objects; therefore, observing the

client for possible aspiration is not appropriate.

• A semi-Fowler's position is appropriate for sleeping, but agnosia is the failure to

recognize familiar objects; therefore, this intervention is inappropriate.

• Placing suction at the bedside will help if the client has dysphagia (difficulty

swallowing), not agnosia, which is failure to recognize familiar objects.

• 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.

TEST TAKING HINT: Be sure to look at what the question is asking and see if the

answer can be determined even if some terms are not understood. In this case, note that the question refers to "collaborative intervention." Only option "4" refers to collaboration with another discipline

The 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 3

• Placing a gait belt prior to ambulating is an appropriate action for safety and

would not require the nurse to intervene.

• Placing the client in a supine position with the head turned to the side is not a

problem position, so the nurse does not need to intervene.

• 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.

• The client should be encouraged and praised for attempting to perform any

activities independently, such as combing hair or brushing teeth.

TEST TAKING HINT: This type of question has three answer options that do not

require a nurse to intervene to correct a subordinate. Remember to read every possible answer option before deciding on a correct one.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?

• An oral anticoagulant medication.
• A beta blocker medication.
• An anti-hyperuricemic medication.
• A thrombolytic medication.

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• 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).

• Beta blockers slow the heart rate and decrease blood pressure but would not

be an anticipated medication to help prevent a TIA secondary to atrial fibrillation.

• An anti-hyperuricemic medication is administered for a client experiencing gout

and decreases the formation of tophi.

• A thrombolytic medication is administered to dissolve a clot, and it may be

ordered during the initial presentation for a client with a CVA but not on discharge.

TEST TAKING HINT: In the stem of this question, there are two disease processes

mentioned—atrial fibrillation and TIA. The reader must determine how one process affects the other before answering the question. In this question, the test taker must know atrial fibrillation predisposes the client to the formation of thrombi, and, therefore, the nurse should anticipate the health-care provider ordering a medication to prevent clot formation, an anticoagulant.