1. A
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?
A. Prepare
to administer recombinant tissue plasminogen activator (rt-PA).
B. Notify
the speech pathologist for an emergency consult.
C. Discuss
the precipitating factors that caused the symptoms.
D. Schedule
for A STAT computer tomography (CT) scan of the head.
2. Which
of the following is most likely associated with a cerebrovascular accident
(CVA) resulting from congenital heart disease?
A. Cardiomyopathy
B. Low
blood pressure
C. Endocarditis
D. Polycythemia
3. The
client has had a right-sided cerebrovascular accident. In transferring the
client from the wheelchair to bed, in what position should a client be placed
to facilitate safe transfer?
A. Weakened
(L) side of the client away from bed.
B. Weakened
(L) side of the cient next to bed.
C. Weakened
(R) side of the cient away from bed.
D. Weakened
(R) side of the client next to bed.
4. A
white female client is admitted to an acute care facility with a diagnosis of
cerebrovascular accident (CVA). Her history reveals bronchial asthma, exogenous
obesity, and iron deficiency anemia. Which history finding is a risk factor for
CVA?
A. Obesity
B. Caucasian
race
C. Bronchial
asthma
D. Female
sex
5. A
70 yr-old client with a diagnosis of leftsided cerebrovascular accident is
admitted to the facility. To prevent the development of diffuse osteoporosis,
which of the following objectives is most appropriate?
A. Promoting
range-of-motion (ROM) exercises
B. Promoting
weight-bearing exercises
C. Maintaining
vitamin levels
D. Maintaining
protein levels
6. A
client who recently had a cerebrovascular accident requires a cane to ambulate.
When teaching about cane use, the rationale for holding a cane on the
uninvolved side is to:
A. maintain
stride length
B. prevent
leaning
C. prevent
edema
D. distribute
weight away from the involved side
7. After
a cerebrovascular accident, a 75 yr old client is admitted to the health care
facility. The client has left-sided weakness and an absent gag reflex. He’s
incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his
hemoglobin is 10 g/dl. Which of the following is a priority for this client?
A. keeping
skin clean and dry
B. checking
stools for occult blood
C. performing
range-of-motion exercises to the left side
D. elevating
the head of the bed to 30 degrees
8. What
is a priority nursing assessment in the first 24 hours after admission of the
client with a thrombotic stroke?
A. Vowel
sounds
B. Cholesterol
level
C. Pupil
size and papillary response
D. Echocardiogram
9. A
male client who has suffered a cerebrovascular accident (CVA) is too weak to
move on his own. To help the client avoid pressure ulcers, the nurse should:
A. perform
passive range-of-motion (ROM) exercises
B. reduce
the client’s fluid intake
C. encourage
the client to use a footboard
D. turn
him frequently
10.
The nurse and unlicensed assistive
personnel (UAP) are caring for a client with right-sided paralysis. Which
action by the UAP requires the nurse to intervene?
A. The
assistant places her hand under the client’s right axilla to help him/her move
up in bed.
B. The
assistant praises the client for attempting to perform ADL’s independently.
C. The
assistant places the client on the back with the client’s head to the side.
D. The
assistant places a gait belt around the client’s waist prior to ambulating.
11.
Which action should take the highest
priority when caring for a client with hemiparesis caused by a cerebrovascular
accident (CVA)?
A. Place
the client on the affected side
B. Use
hand rolls or pillows for support
C. Apply
antiembolism stockings
D. Perform
passive range-of-motion (ROM) exercises
12.
A nurse is caring for a 2 year-old child
after corrective surgery for Tetralogy of Fallot. The mother reports that the
child has suddenly begun seizing. The nurse recognizes this problem is probably
due to
A. Medication
reaction
B. A
cerebral vascular accident
C. Postoperative
meningitis
D. Metabolic
alkalosis
13.
The nurse is caring for a male client
diagnosed with a cerebral aneurysm who reports a severe headache. Which action
should the nurse perform?
A. Call
the physician immediately
B. Sit
with the client for a few minutes
C. Inform
the nurse manager
D. Administer
an analgesic
14.
Which client would the nurse identify as
being most at risk for experiencing a CVA?
A. A
39-year-old pregnant female
B. A
67-year-old Caucasian male
C. A
55-year-old African American male
D. An
84-year-old Japanese female
15.
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?
A. A
beta-blocker medication
B. An
anti-hyperuricemic medication
C. An
oral anticoagulant medication
D. A
thrombolytic medication
16.
During the first 24 hours after thrombolytic
therapy for ischemic stroke, the primary goal is to control the client’s:
A. Respirations
B. Pulse
C. Blood
pressure
D. Temperature
17.
The nurse is formulating a teaching plan
for a client who has just experienced a transient ischemic attack (TIA). Which
fact should the nurse include in the teaching plan?
A. TIA
may be a warning that the client may have cerebrovascular accident (CVA)
B. Most
clients have residual effects after having a TIA
C. TIA
symptoms may last 24 to 48 hours
D. The
most common symptom of TIA is the inability to speak
18.
Regular oral hygiene is an essential
intervention for the client who has had a stroke. Which of the following
nursing measures is inappropriate when providing oral hygiene?
A. Keeping
portable suctioning equipment at the bedside.
B. Opening
the client’s mouth with a padded tongue blade.
C. Cleaning
the client’s mouth and teeth with a toothbrush.
D. Placing
the client on the back with a small pillow under the head.
19.
Ms. Pooja. has had a CVA
(cerebrovascular accident) and has severe right-sided weakness. She has been
taught to walk with a cane. The nurse is evaluating her use of the cane prior
to discharge. Which of the following reflects correct use of the cane?
A. Holding
the cane in her right hand, Ms. Pooja. moves the cane forward first, then her
left leg, and finally her right leg
B. Holding
the cane in her right hand, Ms. Pooja. moves the cane and her right leg
forward, then moves her left leg forward.
C. Holding
the cane in her left hand, Ms. Pooja. moves the cane and her left leg forward,
then moves her right leg forward
D. Holding
the cane in her left hand, Ms. Pooja. moves the cane forward first, then her
right leg, and finally her left leg
20.
What is the expected outcome of
thrombolytic drug therapy?
A. Dissolved
emboli
B. Prevention
of hemorrhage
C. Vasoconstriction
D. Increased
vascular permeability
ANSWER
AND RATIONALS
1. D.
A CT scan will determine if the client is having a stroke or has a brain tumor
or another neurological disorder. This would also determine if it is a
hemorrhagic or ischemic accident and guide the treatment, because only an
ischemic stroke can use rt-PA. This would make preparing to administer
recombinant tissue plasminogen activator (rt-PA) not the priority since if a
stroke was determined to be hemorrhagic, rt-PA is contraindicated. Discuss the
precipitating factors for teaching would not be a priority and slurred speech
would as indicate interference for teaching. Referring the client for speech
therapy would be an intervention after the CVA emergency treatment is
administered according to protocol.
2. D.
The child with congenital heart disease develops polycythemia resulting from an
inadequate mechanism to compensate for decreased oxygen saturation
3. A.
With a right-sided cerebrovascular accident the client would have left-sided
hemiplegia or weakness. The client’s good side should be closest to the bed to
facilitate the transfer.
4. A.
Obesity is a risk factor for CVA. Other risk factors include a history of
ischemic episodes, cardiovascular disease, diabetes mellitus, atherosclerosis
of the cranial vessels, hypertension, polycythemia, smoking,
hypercholesterolemia, oral contraceptive use, emotional stress, family history
of CVA, and advancing age. The client’s race, sex, and bronchial asthma aren’t
risk factors for CVA.
5. B.
When the mechanical stressors of weight bearing are absent, diffuse
osteoporosis can occur. Therefore, if the client does weight-bearing exercises,
disuse complications can be prevented. Maintaining protein and vitamins levels
is important, but neither will prevent osteoporosis. ROM exercises will help
prevent muscle atrophy and contractures.
6. D.
Holding a cane on the uninvolved side distributes weight away from the involved
side. Holding the cane close to the body prevents leaning. Use of a cane won’t
maintain stride length or prevent edema.
7. D.
Because the client’s gag reflex is absent, elevating the head of the bed to 30
degrees helps minimize the client’s risk of aspiration. Checking the stools,
performing ROM exercises, and keeping the skin clean and dry are important, but
preventing aspiration through positioning is the priority.
8. C.
It is crucial to monitor the pupil size and pupillary response to indicate
changes around the cranial nerves. Cholesterol level is an assessment to be
addressed for long-term healthy lifestyle rehabilitation. Bowel sounds need to
be assessed because an ileus or constipation can develop, but is not a priority
in the first 24 hours. An echocardiogram is not needed for the client with a
thrombotic stroke.
9. D.
The most important intervention to prevent pressure ulcers is frequent position
changes, which relieve pressure on the skin and underlying tissues. If pressure
isn’t relieved, capillaries become occluded, reducing circulation and
oxygenation of the tissues and resulting in cell death and ulcer formation.
During passive ROM exercises, the nurse moves each joint through its range of
movement, which improves joint mobility and circulation to the affected area
but doesn’t prevent pressure ulcers. Adequate hydration is necessary to
maintain healthy skin and ensure tissue repair. A footboard prevents plantar
flexion and footdrop by maintaining the foot in a dorsiflexed position.
10. A. This action is inappropriate and
would require intervention by the nurse because pulling on a flaccid shoulder
joint could cause shoulder dislocation; as always use a lift sheet for the
client and nurse safety. All the other actions are appropriate.
11. A. To help prevent airway obstruction
and reduce the risk of aspiration, the nurse should position a client with
hemiparesis on the affected side. Although performing ROM exercises, providing
pillows for support, and applying antiembolism stockings can be appropriate for
a client with CVA, the first concern is to maintain a patent airway.
12. B. Polycythemia occurs as a
physiological reaction to chronic hypoxemia which commonly occurs in clients
with Tetralogy of Fallot. Polycythemia and the resultant increased viscosity of
the blood increase the risk of thromboembolic events. Cerebrovascular accidents
may occur. Signs and symptoms include sudden paralysis, altered speech, extreme
irritability or fatigue, and seizures.
13. A. The headache may be an indication
that the aneurysm is leaking. The nurse should notify the physician
immediately. Sitting with the client is appropriate but only after the
physician has been notified of the change in the client’s condition. The
physician will decide whether or not administration of an analgesic is
indicated. Informing the nurse manager isn’t necessary.
14. C. Africana Americans have twice the
rate of CVA’s as Caucasians; males are more likely to have strokes than females
except in advanced years. Oriental’s have a lower risk, possibly due to their
high omega-3 fatty acids. Pregnancy is a minimal risk factor for CVA.
15. C. Thrombi form secondary to atrial
fibrillation, therefore, an anticoagulant would be anticipated to prevent
thrombi formation; and oral (warfarin [Coumadin]) at discharge verses
intravenous. Beta blockers slow the heart rate and lower the blood pressure.
Anti-hyperuricemic medication is given to clients with gout. Thrombolytic medication
might have been given at initial presentation but would not be a drug
prescribed at discharge.
16. C. Controlling the blood pressure is
critical because an intracerebral hemorrhage is the major adverse effect of
thrombolytic therapy. Blood pressure should be maintained according to
physician and is specific to the client’s ischemic tissue needs and risks of
bleeding from treatment. Other vital signs are monitored, but the priority is
blood pressure.
17. A. TIA may be a warning that the client
will experience a CVA, or stroke, in the near future. TIA aymptoms last no
longer than 24 hours and clients usually have complete recovery after TIA. The
most common symptom of TIA is sudden, painless loss of vision lasting up to 24
hours.
18. D. A helpless client should be positioned
on the side, not on the back. This lateral position helps secretions escape
from the throat and mouth, minimizing the risk of aspiration. It may be
necessary to suction, so having suction equipment at the bedside is necessary.
Padded tongue blades are safe to use. A toothbrush is appropriate to use.
19. D.When a person with weakness on one side uses a cane, there
should always be two points of contact with the floor. When Ms. Pooja. moves
the cane forward, she has both feet on the floor, providing stability. As she
moves the weak leg, the cane and the strong leg provide support. Finally, the
cane, which is even with the weak leg, provides stability while she moves the
strong leg. She should not hold the cane with her weak arm. The use of the cane
requires arm strength to ensure that the cane provides adequate stability when
standing on the weak leg. The cane should be held in the left hand, the hand
opposite the affected leg. If Ms. Pooja. moved the cane and her strong foot at
the same time, she would be left standing on her weak leg at one point. This
would be unstable at best; at worse, impossible
20. A. Thrombolytic therapy is use to
dissolve emboli and reestablish cerebral perfusion.
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