Question 1

The critical care nurse explains to the family of a client who is to receive nimodipine following hemorrhagic stroke that the purpose of this drug is to treat

Accepted Answer

Nimodipine, a calcium-channel blocker, is used to treat vasospasm secondary to subarachnoid hemorrhage.

Question 2

A client had a stroke. A nurse has arranged a consultation with an occupational therapist in order to enhance the client's ability to

Accepted Answer

Occupational therapists work with the client to relearn activities of daily living (ADLs) and to use assistive devices. A vocational therapist would provide training on new job skills. A speech therapist would best provide guidance on swallowing. A physical therapist would teach the client to use a walker.

Question 3

To best help the client who has the nursing diagnosis Ineffective Coping after a stroke, the nurse would

Accepted Answer

All options are valid when caring for a stroke client. However, loss of independence is of particular concern to the client after suffering a stroke. Long-term goals may be difficult to meet and may cause frustration and depression. Breaking the long-term goal into several smaller, more easily attained goals can help the client experience success.

Question 4

A client who has had a stroke appears to understand words that are spoken but cannot verbally respond. The nurse clarifies that this type of aphasia is

Accepted Answer

Broca's (expressive or motor) aphasia affects speech production as a result of an infarction in the frontal lobe of the brain.

Question 5

The nurse assesses agnosia in a client who had a CVA. An example of this disturbance would be an inability to

Accepted Answer

Agnosia is a disturbance in the ability to recognize familiar objects through the senses. The most common types are visual and auditory. A client with visual agnosia may examine objects curiously but be unable to determine their function.

Question 6

When the spouse of a client who has had a CVA as a result of a cerebral hemorrhage asks the nurse about the client's chances for recovery, the nurse should base a reply on knowledge that with this type of CVA

Accepted Answer

Hemorrhagic strokes usually produce extensive residual function loss and have the slowest recovery of all types of stroke.

Question 7

A client who has left hemiparesis as a result of stroke is getting out of bed to the chair for the first time. The nurse should position the chair

Accepted Answer

It is safest to have the client pivot on the unaffected side. Therefore position the chair at a right angle to the unaffected side.

Question 8

The nursing action that would be appropriate in caring for a client who has experienced stroke because of hemorrhage is to

Accepted Answer

Straining at stool or with excessive coughing, vomiting, lifting, or use of the arms to change position should be avoided, because the Valsalva maneuver increases intracerebral pressure.

Question 9

An emergency department nurse is admitting a client with ischemic stroke who is eligible for thrombolytic therapy. The nurse works quickly to provide care, knowing that for this therapy to be effective, it must be administered in a post-stroke time window of

Accepted Answer

Thrombolytic therapy must be administered as soon as possible after the onset of the stroke; a treatment window of 3 hours from the onset of manifestations has been established.

Question 10

When the client complains about having to perform quadricep-setting exercises, the nurse reminds him that the exercises will enhance ambulation by

Accepted Answer

The quad-setting exercises strengthen and stabilize the knee, which is essential to the initiation of ambulation.

Question 11

A client with stroke has a nursing diagnosis of Impaired Verbal Communication and has specific difficulty in verbal expression. The most helpful strategy by the nurse would be to

Accepted Answer

When a client has difficulty with verbal expression, give the client practice in repeating words after you.

Question 12

When a client has undergone a carotid endarterectomy and has been returned to the nursing unit with stable vital signs, the nurse should

Accepted Answer

Postoperative care after carotid endarterectomy includes neurologic assessments every 1 to 2 hours. Keep the client's head aligned in a straight position to help maintain airway patency and to minimize stress on the operative site. Elevate the head of the bed when vital signs are stable. Maintain the client's blood pressure within 20 mm Hg of the preoperative normal values.

Question 13

The nurse encourages a stroke victim by telling them that following a cerebrovascular accident (CVA) caused by thrombosis, the client's condition may improve after several days as a result of

Accepted Answer

The area of edema after ischemia may lead to temporary neurologic deficits. Edema may subside in a few hours or sometimes in several days, and the client may regain some function.

Question 14

Safety precautions the nurse instructs the client with homonymous hemianopsia to use include

Accepted Answer

Clients with homonymous hemianopsia cannot see past the midline without turning the head toward that side. This can create a safety concern for the client. The client may run into objects, trip, or fall.

Question 15

A client who had a thrombotic stroke finished receiving intravenous rt-PA therapy at 10:00 AM on Sunday. Sunday afternoon the physician writes an order to start Coumadin and Plavix that evening. The most appropriate action by the nurse would be to

Accepted Answer

Bleeding, which can be severe or even fatal, is a possible complication of rt-TPA. Fatal hemorrhages generally occur within the first 24 hours after rt-TPA. Therefore anticoagulants and antiplatelet medications are not recommended until 24 hours after administration of rt-TPA.

Question 16

A client has a history of experiencing focal neurologic deficits, such as slurred speech and facial weakness, that last for a few hours at a time. The nurse then assesses this client for other possible manifestations of

Accepted Answer

TIAs are focal neurologic deficits lasting less than 24 hours that produce manifestations of slurred speech, facial weakness, and ataxia.

Question 17

To promote safety, when a client complains of the effects of diplopia after a stroke, the nurse would

Accepted Answer

Diplopia (double vision) is a common visual disturbance after a stroke. Visual disturbances make the client more prone to injury. Patching one eye removes the second image and promotes better vision, which in turn helps keep the client safe. Alternating the patching helps maintain the function and strength of the extraocular muscles in both eyes.

Question 18

A client who experienced a stroke that left residual left hemiplegia will not wash the left side or use her good limbs on the right to move or adjust the limbs on the left. The most appropriate diagnosis for this client is

Accepted Answer

Unilateral Neglect describes a condition in which the client has no awareness of one side of the body. Clinical manifestations of unilateral neglect include failure to (1) attend to one side of the body, (2) report or respond to stimuli on one side of the body, (3) use one extremity, and (4) orient the head and eyes to one side. Because of this condition, the client could have a partial Self-Care Deficit and may also experience Ineffective Coping, but the reason behind the problem remains the lack of awareness of that one side.

Question 19

The assessment the nurse documents that supports the finding of apraxia would be the client's inability to

Accepted Answer

In apraxia the client cannot carry out a skilled act such as dressing in the absence of paralysis.

Question 20

The nurse is caring for a client who had a stroke several years ago. The client has indicators of being malnourished. The nurse would assess the client for which of the following?

Accepted Answer

In general, the dysphagic client is taught not to throw the head back to propel the food to the back of the mouth, as this can cause aspiration. The bowel's ability to absorb nutrients is not disrupted by a stroke. Clients should usually hold the head in a midline position with the neck slightly flexed forward. Clients with dysphagia are often embarrassed and frustrated by their eating and swallowing problems and often avoid eating.

Quiz 70: Management of Clients with Stroke