Chapter 70: Management of Clients with Stroke Nursing School Test Banks

Black & Hawks: Medical-Surgical Nursing, 8th Edition

Test Bank

Chapter 70: Management of Clients with Stroke

MULTIPLE CHOICE

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

a.

decrease of edema in the area.

b.

formation of collateral blood circulation.

c.

formation of new nervous pathways.

d.

reabsorption of the thrombus.

ANS: A

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.

DIF: Comprehension/Understanding REF: p. 1846 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

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

a.

improvement generally occurs over several days.

b.

rapid improvement often occurs.

c.

recovery is slow and less complete.

d.

there is no way to know for sure.

ANS: C

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

DIF: Application/Applying REF: p. 1844 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

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

a.

read and comprehend writing.

b.

recognize eating utensils.

c.

see past the midline.

d.

use the limbs purposefully.

ANS: B

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.

DIF: Application/Applying REF: p. 1849 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

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

a.

approach the client on the unaffected side.

b.

place a patch over one eye.

c.

reassure the client that the problem is temporary.

d.

teach eye muscle exercises.

ANS: B

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.

DIF: Application/Applying REF: p. 1862 OBJ: Intervention

MSC: Safe, Effective Care Environment Safety and Infection Control-Injury Prevention

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

a.

assess neurologic status every 4 hours.

b.

keep the client in a flat, supine position with the head flexed.

c.

maintain blood pressure within 20 mm Hg of the preoperative values.

d.

provide neck range-of-motion exercises every 8 hours.

ANS: C

Postoperative care after carotid endarterectomy includes neurologic assessments every 1 to 2 hours. Keep the clients 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 clients blood pressure within 20 mm Hg of the preoperative normal values.

DIF: Application/Applying REF: p. 1869 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

6. 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

a.

dizziness.

b.

hypertension.

c.

spasticity.

d.

vasospasm.

ANS: D

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

DIF: Comprehension/Understanding REF: p. 1858 OBJ: Intervention

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Pharmacological Agents/Actions

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

a.

maintain the head of the bed in a flat position.

b.

monitor rectal temperature every 4 hours.

c.

teach isometric exercises.

d.

teach the client to avoid the Valsalva maneuver.

ANS: D

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.

DIF: Application/Applying REF: p. 1858 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

8. 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

a.

30 minutes.

b.

3 hours.

c.

6 hours.

d.

12 hours.

ANS: B

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.

DIF: Knowledge/Remembering REF: p. 1851 OBJ: Intervention

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Pharmacological Agents/Actions

9. 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

a.

embolic stroke.

b.

encephalopathy.

c.

intracranial hemorrhage.

d.

transient ischemic attacks (TIAs).

ANS: D

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

DIF: Application/Applying REF: p. 1867 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

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

a.

break a long-term goal into smaller pieces.

b.

listen to the client carefully and try to understand.

c.

place familiar items, such as photos, near the bed.

d.

redirect the client when inappropriate behavior occurs.

ANS: A

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.

DIF: Application/Applying REF: p. 1865 OBJ: Intervention

MSC: Psychosocial Integrity Coping and Adaptation-Coping Mechanisms

11. 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

a.

Brocas.

b.

global.

c.

receptive.

d.

Wernickes.

ANS: A

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

DIF: Knowledge/Remembering REF: p. 1847 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

12. The assessment the nurse documents that supports the finding of apraxia would be the clients inability to

a.

get dressed independently.

b.

recognize a pencil.

c.

see far objects.

d.

understand the spoken word.

ANS: A

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

DIF: Comprehension/Understanding REF: p. 1849 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

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

a.

getting evaluated for prescription lenses.

b.

turning the head to scan the visual field.

c.

using artificial tears to keep the eyes moist.

d.

wearing an eye patch on alternating eyes.

ANS: B

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.

DIF: Application/Applying REF: p. 1849 OBJ: Intervention

MSC: Safe, Effective Care Environment Safety and Infection Control-Injury Prevention

14. 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

a.

Altered Physical Mobility.

b.

Ineffective Coping.

c.

Self-Care Deficit.

d.

Unilateral Neglect.

ANS: D

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.

DIF: Application/Applying REF: p. 1865 OBJ: Diagnosis

MSC: Psychosocial Integrity Psychosocial Adaptation-Sensory/Perceptual Alterations

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

a.

call the physician and clarify when the medications should be given.

b.

consult with the pharmacist about giving both medications together.

c.

give the Coumadin at 5:00 PM because that is the standard administration time.

d.

provide appropriate education and administer the medications as ordered.

ANS: A

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.

DIF: Analysis/Analyzing REF: p. 1855 OBJ: Intervention

MSC: Safe, Effective Care Environment Safety and Infection Control-Injury Prevention

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

a.

acquire job skills.

b.

feed himself.

c.

swallow.

d.

use a walker.

ANS: B

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.

DIF: Comprehension/Understanding REF: pp. 1862-1863

OBJ: Intervention

MSC: Safe, Effective Care Environment Management of Care-Consultation

17. 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

a.

at a right angle to the clients left side.

b.

at a right angle to the clients right side.

c.

facing away from the side of the bed.

d.

facing the side of the bed but within 1 foot.

ANS: B

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

DIF: Application/Applying REF: pp. 1859-1860

OBJ: Intervention

MSC: Safe, Effective Care Environment Safety and Infection Control-Injury Prevention

18. 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?

a.

Ability to throw the head back to propel the food

b.

Embarrassment and frustration over trouble eating

c.

Inability of the bowel to absorb nutrients

d.

Positioning the head with a sideways tilt

ANS: B

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 bowels 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.

DIF: Application/Applying REF: p. 1862 OBJ: Intervention

MSC: Psychosocial Integrity Coping and Adaptation-Coping Mechanisms

19. 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

a.

give the client practice in repeating words after the nurse.

b.

point to objects and state their names.

c.

repeat directions until they are understood.

d.

try to do all the speaking for the client.

ANS: A

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

DIF: Application/Applying REF: p. 1864 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Illness Management

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

a.

combating footdrop.

b.

diminishing the effects of proprioception.

c.

improving balance.

d.

strengthening the knee.

ANS: D

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

DIF: Comprehension/Understanding REF: p. 1859 OBJ: Intervention

MSC: Physiological Integrity Basic Care and Comfort-Mobility/Immobility

21. The nurse would assess the client with a history of TIAs for

a.

ataxia and dysarthria.

b.

bouts of hypertension.

c.

nausea and vomiting.

d.

tingling in the extremities.

ANS: A

Manifestations of a TIA in the vertebrobasilar circulation include two or more of the following: vertigo, diplopia, dysphagia, dysarthria, and ataxia.

DIF: Application/Applying REF: p. 1867 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

22. A client has had two TIAs. Priority nursing actions focus on

a.

helping the client reduce risk factors for stroke.

b.

providing emotional support during this stressful time.

c.

teaching the clients family about rehabilitation.

d.

working with a speech therapist on speech problems.

ANS: A

Priority nursing care and the goal of medical management after a TIA is preventing progression to stroke. The client should be assisted to understand his/her risk factors for stroke and to develop a plan to reduce them.

DIF: Application REF: p. 1867 OBJ: Intervention

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Disease Prevention

23. A client has received thrombolytic therapy for treatment of an ischemic stroke. Which intervention takes priority?

a.

Assessing nutritional status and planning feeding

b.

Consulting with the interdisciplinary stroke team

c.

Providing client and family education

d.

Stringent blood pressure control

ANS: D

Cerebral hemorrhage is the most catastrophic adverse effect of thrombolytic therapy. Stringent blood pressure management is the most important intervention to prevent intracranial hemorrhage after thrombolysis. All interventions are important in the stroke client but preventing further damage is the priority.

DIF: Application/Applying REF: p. 1855 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications of Diagnostic Tests/Treatments/Procedures

MULTIPLE RESPONSE

1. A client is admitted to the hospital with right-sided hemiplegia as a result of a stroke. To help prevent contractures, the nurse should employ which of the following interventions? (Select all that apply.)

a.

Give the client a ball to hold to keep fingers in the flexed position.

b.

Perform passive ROM to affected limbs at least twice a day after the first 24 hours.

c.

Support a completely flaccid arm with pillows when in bed or in a chair.

d.

Try placing the client in the prone position for 15-30 minutes at a time.

e.

Use high-top tennis shoes or orthotics while in bed to prevent footdrop.

ANS: B, C, D, E

There are several interventions for the client to prevent contractures, including performing passive ROM, supporting a completely flaccid arm to prevent frozen shoulder, positioning the client in the prone position, if tolerated, to hyperextend the hip joints, and preventing footdrop by using high-top tennis shoes or orthotics. Giving the client a ball to squeeze actually promotes flexion when extension is needed.

DIF: Application/Applying REF: p. 1861 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

2. A nurse teaches a community class about primary prevention for stroke, which includes (Select all that apply)

a.

adequate control of hypertension.

b.

keeping tight glycemic control in diabetes.

c.

maintaining safe cholesterol levels.

d.

not smoking or smoking cessation.

e.

reducing heavy alcohol consumption.

ANS: C, D, E

Risk factors are similar to those for coronary artery disease and include obesity, hyperlipidemia, smoking, heavy alcohol intake, using illicit drugs, and using hormone-based birth control (except for low-dose estrogen in the absence of other risk factors). Reduction of any of these risk factors can help decrease the chance of having a stroke. Maintaining good control of hypertension and diabetes would be considered secondary prevention for stroke.

DIF: Comprehension/Understanding REF: p. 1845 OBJ: Intervention

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Disease Prevention

3. The nurse has consulted with the interdisciplinary stroke team to facilitate a clients discharge to home from the rehabilitation facility. The occupational therapist recommends a therapeutic day pass. The nurse explains to the family that the purpose of the pass is to (Select all that apply)

a.

allow the client to practice self-care skills.

b.

evaluate the accessibility and safety of the home.

c.

help the family adjust to the clients presence.

d.

improve transition back into the community.

e.

reduce the cost of the rehabilitation stay.

ANS: A, C, D

A therapeutic pass allows the client to go home for short stays, often initially for 8 hours or so, then lengthening into a weekend stay. This pass allows the client to practice self-care, helps the family adjust to the client and the clients limitations, improves the transition back into the community, and allows for practice in decision-making skills. It is not designed to reduce the cost of the rehabilitation stay. A rehabilitation home visits purpose is to evaluate the accessibility and safety of the home environment.

DIF: Application/Applying REF: p. 1866 OBJ: Intervention

MSC: Safe, Effective Care Environment Management of Care-Collaboration with Interdisciplinary Team

4. Self-care measures the nurse or speech therapist should teach the client who has residual dysphagia after a stroke include (Select all that apply)

a.

chewing each bite thoroughly.

b.

placing foods in the unaffected side of the mouth.

c.

sticking to only semi-liquids and very soft foods.

d.

turning the head to the unaffected side and checking for retained food.

ANS: A, B, D

A feeding plan for the client will be individualized to the clients ability to swallow; therefore no generalized rule about the types of foods allowed is possible. Options a, b, and d are areas taught to dysphagic clients, along with alternating liquids with solids if possible and avoiding thin liquids

DIF: Application/Applying REF: p. 1863 OBJ: Intervention

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Self Care

5. Which interventions should the nurse plan to encourage the client to become proficient in self-administering his/her own medications? (Select all that apply.)

a.

Allow the client to assume greater responsibility for taking medications.

b.

Create a clear, concise drug chart including all the clients medications.

c.

Encourage the client to take medications under supervision of a family member.

d.

Provide a supervised trial of self-administration of medications.

e.

Teach the client pertinent information about each medication.

ANS: A, B, D, E

All options but c will help the client assume greater responsibility for self-administration of medications, which is a goal for self-care.

DIF: Application/Applying REF: p. 1866 OBJ: Intervention

MSC: Physiological Integrity

Elsevier items and derived items 2009 by Saunders, an imprint of Elsevier Inc.

Some material was previously published.

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