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Pepu test 6
Terms in this set (166)
Evaluating the level of consciousness using the Glasgow Coma Scale is an essential nursing assessment for a patient who has had an intracerebral hemorrhage. Which of the following scores would indicate the need for immediate intubation?
B, Scores on the Glasgow Coma Scale range from 3 to 15. A score of 8 or less is cause for immediate intubatio
A patient is admitted via ambulance to the emergency room of a stroke center at 1:30 p.m. with symptoms that the patient said began at 1:00 p.m. Within 1 hour, an ischemic stroke had been confirmed and the doctor ordered tPA. The nurse knows to give this drug no later than what time?
a) 4:00 p.m.
b) 5:30 p.m.
c) 2:30 p.m.
d) 3:00 p.m.
A, Tissue plasminogen activator (tPA) must be given within 3 hours after symptom onset. Therefore, since symptom onset was 1:00 pm, the window of opportunity ends at 4:00 pm.
When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke?
a) The day the patient has the stroke
b) After the patient has passed the acute phase of the stroke
c) The day before the patient is discharged
d) After the nurse has received the discharge orders
A, Although rehabilitation begins on the day the patient has the stroke, the process is intensified during convalescence and requires a coordinated team effor
From which direction should a nurse approach a client who is blind in the right eye?
a) From directly behind the client
b) From the right side of the client
c) From directly in front of the client
d) From the left side of the client
D, The nurse should approach the client from the left side so that the client can be aware of the nurse's approach. Likewise, personal items should be placed on the client's left side so that he can see them easily.
The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient?
A, The head of the bed is elevated 15 to 30 degrees (semi-Fowler's position) to promote venous drainage and decrease intracranial pressure.
Which of the following psychotropic drug classifications is often prescribed for neuropathic pain?
b) Tricyclic antidepressants
d) Mood stabilizers
B,Tricyclic antidepressants are often prescribed for neuropathic pain
A client recently experienced a stroke with accompanying left-sided paralysis. His family voices concerns about how to best interact with him. They report the client doesn't seem aware of their presence when they approach him on his left side. What advice should the nurse give the family?
a) "The client is unaware of his left side. You should approach him on the right side."
b) "The client is unaware of his left side. You need to encourage him to interact from this side."
c) "The client is feeling an emotional loss. He'll eventually start acknowledging you on his left side."
d) "This condition is temporary."
A, The client is experiencing unilateral neglect and is unaware of his left side. The nurse should advise the family to approach him on his nonaffected (right) side. Approaching the client on the affected side would be counterproductive. It's too premature to make the determination whether this condition will be permanent.
During a class on stroke, a junior nursing student asks what the clinical manifestations of stroke are. What would be the instructor's best answer?
a) "Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation."
b) "Clinical manifestations of a stroke are highly variable, depending on the cardiovascular health of the client."
c) "Clinical manifestations of a stroke depend on how quickly the clot can be dissolved."
d) "Clinical manifestations of a stroke generally include aphasia, one-sided flaccidity, and trouble swallowing."
A, Clinical manifestations following a stroke are highly variable and depend on the area of the cerebral cortex and the affected hemisphere, the degree of blockage (total, partial), and the presence or absence of adequate collateral circulation. (Collateral circulation is circulation formed by smaller blood vessels branching off from or near larger occluded vessels.) Clinical manifestations of a stroke do not depend on the cardiovascular health of the client or how quickly the clot can be dissolved. Clinical manifestations of a stroke are not "general" but individual.
Which of the following terms refers to blindness in the right or left halves of the visual fields of both eyes?
d) Homonymous hemianopsia
D, Homonymous hemianopsia occurs with occipital lobe tumors. Scotoma refers to a defect in vision in a specific area in one or both eyes. Diplopia refers to double vision or the awareness of two images of the same object occurring in one or both eyes. Nystagmus refers to rhythmic, involuntary movements or oscillations of the eyes
A client is hospitalized when they present to the Emergency Department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to their presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what?
a) Right-sided stroke
b) Transient ischemic attack
c) Left-sided stroke
d) Cerebral aneurysm
B, A transient ischemic attack (TIA) is a sudden, brief attack of neurologic impairment caused by a temporary interruption in cerebral blood flow. Symptoms may disappear within 1 hour; some continue for as long as 1 day. When the symptoms terminate, the client resumes his or her presymptomatic state. The symptoms do not describe a left- or right-sided stroke or a cerebral aneurysm
The nurse understands the urgency of timely intervention for an ischemic stroke. Based on her knowledge of cerebral blood flow (normal CBF = 50 to 55 mL/100 g/min) and obstruction, she is aware that neurons will no longer maintain aerobic respiration at which level of CBF?
a) 35 to 45 mL/100 g/min
b) 35 to 45 mL/100 g/min
c) 45 to 50 mL/100 g/min
d) 15 to 20 mL/100 g/min
When developing a care plan for a client who has recently suffered a stroke, a nurse includes the nursing diagnosis Risk for imbalanced body temperature. What is the rationale for this diagnosis?
a) A decreased body temperature will signal the need to cover the client.
b) An elevated body temperature indicates infection.
c) An elevated temperature indicates cerebellum malfunction.
d) The stroke may have impacted the body's thermoregulation centers.
A patient diagnosed with an ischemic stroke should be treated within the first 3 hours of symptom onset with which of the following?
b) Extended release dipyridamole
c) Tissue plasminogen activator (tPA)
The nurse is caring for a client who has had a cerebrovascular accident. The client has a nursing diagnosis of altered nutritional status related to difficulty swallowing. What intervention would it be important for the nurse to institute?
a) Encourage the client to eat semisolid foods and cold foods.
b) Encourage the client to drink hot liquids.
c) Encourage the client to eat tepid foods.
d) Encourage the client to eat solid foods.
A patient presents to the emergency room with complaints of having an "exploding headache" for the last 2 hours. The patient is immediately seen by a triage nurse who suspects the patient is experiencing a stroke. Which of the following is a possible cause based on the characteristic symptom?
a) Cardiogenic emboli
b) Small artery thrombosis
c) Large artery thrombosis
d) Cerebral aneurysm
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