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TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

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Chapter67:ManagementofPatientswithCerebrovascularDisorders  1.

Apatienthashadanischemicstrokeandhasbeenadmittedtothemedicalunit.Whatactionshouldthe nurseperformtobestpreventjointdeformities?

A)

Placethepatientinthepronepositionfor30minutes/day.

B)

Assistthepatientinacutelyflexingthethightopromotemovement.

C)

Placeapillowintheaxillawhenthereislimitedexternalrotation.

D)

Placepatientshandinpronation.

Ans:

C Feedback: Apillowintheaxillapreventsadductionoftheaffectedshoulderandkeepsthearmawayfromthe chest.Thepronepositionwithapillowunderthepelvis,notflat,promoteshyperextensionofthehip joints,essentialfornormalgait.Topromotevenousreturnandpreventedema,theupperthighshould notbeflexedacutely.Thehandisplacedinslightsupination,notpronation,whichisitsmostfunctional position.

2.

Apatientdiagnosedwithtransientischemicattacks(TIAs)isscheduledforacarotidendarterectomy. Thenurseexplainsthatthisprocedurewillbedoneforwhatpurpose?

A)

Todecreasecerebraledema

B)

TopreventseizureactivitythatiscommonfollowingaTIA

C)

Toremoveatheroscleroticplaquesblockingcerebralflow

D)

TodeterminethecauseoftheTIA

Ans:

C Feedback: ThemainsurgicalprocedureforselectpatientswithTIAsiscarotidendarterectomy,theremovalofan atheroscleroticplaqueorthrombusfromthecarotidarterytopreventstrokein patientswithocclusivediseaseoftheextracranialarteries.Anendarterectomydoesnotdecreasecerebral edema,preventseizureactivity,ordeterminethecauseofaTIA.

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

3.

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Thenurseisdischarginghomeapatientwhosufferedastroke.Hehasaflaccidrightarmandlegandis experiencingproblemswithurinaryincontinence.Thenursemakesareferraltoahomehealthnurse becauseofanawarenessofwhatcommonpatientresponsetoachangeinbodyimage?

A)

Denial

B)

Fear

C)

Depression

D)

Disassociation

Ans:

C Feedback: Depressionisacommonandseriousprobleminthepatientwhohashadastroke.Itcanresultfroma profounddisruptioninhisorherlifeandchangesintotalfunction,leavingthepatientwithalossof independence.Thenurseneedstoencouragethepatienttoverbalizefeelingstoassesstheeffectofthe strokeonself-esteem.Denial,fear,anddisassociationarenotthemostcommonpatientresponsetoa changeinbodyimage,althougheachcanoccurinsomepatients.

4.

Whencaringforapatientwhohadahemorrhagicstroke,closemonitoringofvitalsignsandneurologic changesisimperative.Whatistheearliestsignofdeteriorationinapatientwithahemorrhagicstrokeof whichthenurseshouldbeaware?

A)

Generalizedpain

B)

Alterationinlevelofconsciousness(LOC)

C)

Tonicclonicseizures

D)

Shortnessofbreath

Ans:

B Feedback: AlterationinLOCistheearliestsignofdeteriorationinapatientafterahemorrhagicstroke,suchas milddrowsiness,slightslurringofspeech,andsluggishpapillaryreaction.Suddenheadachemayoccur, butgeneralizedpainislesscommon.Seizuresandshortnessofbreatharenotidentifiedasearlysignsof hemorrhagicstroke.

5.

Thenurseisperformingstrokeriskscreeningsatahospitalopenhouse.Thenursehasidentifiedfour patientswhomightbeatriskforastroke.Whichpatientislikelyatthehighestriskforahemorrhagic stroke?

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

A)

Whitefemale,age60,withhistoryofexcessivealcoholintake

B)

Whitemale,age60,withhistoryofuncontrolledhypertension

C)

Blackmale,age60,withhistoryofdiabetes

D)

Blackmale,age50,withhistoryofsmoking

Ans:

B

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Feedback: Uncontrolledhypertensionistheprimarycauseofahemorrhagicstroke.Controlofhypertension, especiallyinindividualsover55yearsofage,clearlyreducestheriskforhemorrhagicstroke.Additional riskfactorsareincreasedage,malegender,andexcessivealcoholintake.Anotherhigh-riskgroup includesAfricanAmericans,wheretheincidenceoffirststrokeisalmosttwicethatasinCaucasians. 6.

ApatientwhojustsufferedasuspectedischemicstrokeisbroughttotheEDbyambulance.Onwhat shouldthenursesprimaryassessmentfocus?

A)

Cardiacandrespiratorystatus

B)

Seizureactivity

C)

Pain

D)

Fluidandelectrolytebalance

Ans:

A Feedback: AcutecarebeginswithmanagingABCs.Patientsmayhavedifficultykeepinganopenandclearairway secondarytodecreasedLOC.Neurologicassessmentwithclosemonitoringforsignsofincreased neurologicdeficitandseizureactivityoccursnext.Fluidandelectrolytebalancemustbecontrolled carefullywiththegoalofadequatehydrationtopromoteperfusionanddecreasefurtherbrainactivity.

7.

Apatientwithacerebralaneurysmexhibitssignsandsymptomsofanincreaseinintracranialpressure (ICP).Whatnursinginterventionwouldbemostappropriateforthispatient?

A)

Range-of-motionexercisestopreventcontractures

B)

EncouragingindependencewithADLstopromoterecovery

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

C)

Earlyinitiationofphysicaltherapy

D)

Absolutebedrestinaquiet,nonstimulatingenvironment

Ans:

D

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Feedback: Thepatientisplacedonimmediateandabsolutebedrestinaquiet,nonstressfulenvironmentbecause activity,pain,andanxietyelevateBP,whichincreasestheriskforbleeding.Visitorsarerestricted.The nurseadministersallpersonalcare.Thepatientisfedandbathedtopreventanyexertionthatmightraise BP. 8.

Apatientrecoveringfromastrokehassevereshoulderpainfromsubluxationoftheshoulderandis beingcaredforontheunit.Topreventfurtherinjuryandpain,thenursecaringforthispatientisaware ofwhatprincipleofcare?

A)

Thepatientshouldbefittedwithacastbecauseuseofaslingshouldbeavoidedduetoadduction oftheaffectedshoulder.

B)

Elevationofthearmandhandcanleadtofurthercomplicationsassociatedwithedema.

C)

Passivelyexercisingtheaffectedextremityisavoidedinordertominimizepain.

D)

Thepatientshouldbetaughttointerlacefingers,placepalmstogether,andslowlybringscapulae forwardtoavoidexcessiveforcetoshoulder.

Ans:

D Feedback: Topreventshoulderpain,thenurseshouldneverliftapatientbytheflaccidshoulderorpullonthe affectedarmorshoulder.Thepatientistaughthowtomoveandexercisetheaffectedarm/shoulder throughpropermovementandpositioning.Thepatientisinstructedtointerlacethefingers,placethe palmstogether,andpushtheclaspedhandsslowlyforwardtobringthescapulaeforward;heorshethen raisesbothhandsabovethehead.Thisisrepeatedthroughouttheday.Theuseofaproperlywornsling whenthepatientisoutofbedpreventstheparalyzedupperextremityfromdanglingwithoutsupport. Range-of-motionexercisesarestillvitallyimportantinpreventingafrozenshoulderandultimately atrophyofsubcutaneoustissues,whichcancausemorepain.Elevationofthearmandhandisalso importantinpreventingdependentedemaofthehand.

9.

Thepatienthasbeendiagnosedwithaphasiaaftersufferingastroke.Whatcanthenursedotobestmake thepatientsatmospheremoreconducivetocommunication?

A)

Provideaboardofcommonlyusedneedsandphrases.

B)

Havethepatientspeaktolovedonesonthephonedaily.

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

C)

Helpthepatientcompletehisorhersentences.

D)

Speakinaloudanddeliberatevoicetothepatient.

Ans:

A

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Feedback: Theinabilitytotalkonthetelephoneoransweraquestionorexclusionfromconversationcausesanger, frustration,fearofthefuture,andhopelessness.Acommonpitfallisforthenurseorotherhealthcare teammembertocompletethethoughtsorsentencesofthepatient.Thisshouldbeavoidedbecauseit maycausethepatienttofeelmorefrustratedatnotbeingallowedtospeakandmaydetereffortsto practiceputtingthoughtstogetherandcompletingasentence.Thepatientmayalsobenefitfroma communicationboard,whichhaspicturesofcommonlyrequestedneedsandphrases.Theboardmaybe translatedintoseverallanguages. 10. Thenurseisassessingapatientwithasuspectedstroke.Whatassessmentfindingismostsuggestiveofa stroke? A)

Facialdroop

B)

Dysrhythmias

C)

Periorbitaledema

D)

Projectilevomiting

Ans:

A Feedback: Facialdroopingorasymmetryisaclassicabnormalfindingonaphysicalassessmentthatmaybe associatedwithastroke.Facialedemaisnotsuggestiveofastrokeandpatientslesscommonly experiencedysrhythmiasorvomiting.

11. Thenurseiscaringforapatientdiagnosedwithanischemicstrokeandknowsthateffectivepositioning ofthepatientisimportant.Whichofthefollowingshouldbeintegratedintothepatientsplanofcare? A)

Thepatientshipjointshouldbemaintainedinaflexedposition.

B)

Thepatientshouldbeinasupinepositionunlessambulating.

C)

Thepatientshouldbeplacedinapronepositionfor15to30minutesseveraltimesaday.

D)

ThepatientshouldbeplacedinaTrendelenbergpositiontwotothreetimesdailytopromote

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

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cerebralperfusion. Ans:

C Feedback: Ifpossible,thepatientisplacedinapronepositionfor15to30minutesseveraltimesaday.Asmall pilloworasupportisplacedunderthepelvis,extendingfromtheleveloftheumbilicustotheupper thirdofthethigh.Thishelpstopromotehyperextensionofthehipjoints,whichisessentialfornormal gait,andhelpspreventkneeandhipflexioncontractures.Thehipjointsshouldnotbemaintainedin flexionandtheTrendelenbergpositionisnotindicated.

12. ApatienthasbeenadmittedtotheICUafterbeingrecentlydiagnosedwithananeurysmandthepatients admissionordersincludespecificaneurysmprecautions.Whatnursingactionwillthenurseincorporate intothepatientsplanofcare? A)

Elevatetheheadofthebedto45degrees.

B)

Maintainthepatientoncompletebedrest.

C)

Administerenemaswhenthepatientisconstipated.

D)

Avoiduseofthigh-highelasticcompressionstockings.

Ans:

B Feedback: Cerebralaneurysmprecautionsareimplementedforthepatientwithadiagnosisofaneurysmtoprovide anonstimulatingenvironment,preventincreasesinICP,andpreventfurtherbleeding.Thepatientis placedonimmediateandabsolutebedrestinaquiet,nonstressfulenvironmentbecauseactivity,pain, andanxietyelevateBP,whichincreasestheriskforbleeding.Visitors,exceptforfamily,arerestricted. Theheadofthebediselevated15to30degreestopromotevenousdrainageanddecreaseICP.Some neurologists,however,preferthatthepatientremainsflattoincreasecerebralperfusion.Noenemasare permitted,butstoolsoftenersandmildlaxativesareprescribed.Thigh-highelasticcompression stockingsorsequentialcompressionbootsmaybeorderedtodecreasethepatientsriskfordeepvein thrombosis(DVT).

13. Anurseiscaringforapatientdiagnosedwithahemorrhagicstroke.Whencreatingthispatientsplanof care,whatgoalshouldbeprioritized? A)

Preventcomplicationsofimmobility.

B)

Maintainandimprovecerebraltissueperfusion.

C)

Relieveanxietyandpain.

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

D)

Relievesensorydeprivation.

Ans:

B

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Feedback: Eachofthelistedgoalsisappropriateinthecareofapatientrecoveringfromastroke.However, promotingcerebralperfusionisapriorityphysiologicneed,onwhichthepatientssurvivaldepends. 14. Thenurseispreparinghealtheducationforapatientwhoisbeingdischargedafterhospitalizationfora hemorrhagicstroke.Whatcontentshouldthenurseincludeinthiseducation? A)

Mild,intermittentseizurescanbeexpected.

B)

Takeibuprofenforcomplaintsofaseriousheadache.

C)

Takeantihypertensivemedicationasordered.

D)

Drowsinessisnormalforthefirstweekafterdischarge.

Ans:

C Feedback: Thepatientandfamilyareprovidedwithinformationthatwillenablethemtocooperatewiththecare andrestrictionsrequiredduringtheacutephaseofhemorrhagicstrokeandtopreparethepatientto returnhome.Patientandfamilyteachingincludesinformationaboutthecausesofhemorrhagicstroke anditspossibleconsequences.Symptomsofhydrocephalusincludegradualonsetofdrowsinessand behavioralchanges.Hypertensionisthemostseriousriskfactor,suggestingthatappropriate antihypertensivetreatmentisessentialforapatientbeingdischarged.Seizureactivityisnotnormal; complaintsofaseriousheadacheshouldbereportedtothephysicianbeforeanymedicationistaken. Drowsinessisnotnormalorexpected.

15. Apatientdiagnosedwithacerebralaneurysmreportsasevereheadachetothenurse.Whatactionisa priorityforthenurse? A)

Sitwiththepatientforafewminutes.

B)

Administerananalgesic.

C)

Informthenurse-manager.

D)

Callthephysicianimmediately.

Ans:

D

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

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Feedback: Aheadachemaybeanindicationthattheaneurysmisleaking.Thenurseshouldnotifythephysician immediately.Thephysicianwilldecidewhetheradministrationofananalgesicisindicated.Informing thenurse-managerisnotnecessary.Sittingwiththepatientisappropriate,oncethephysicianhasbeen notifiedofthechangeinthepatientscondition. 16. ApatientisbroughtbyambulancetotheEDaftersufferingwhatthefamilythinksisastroke.Thenurse caringforthispatientisawarethatanabsolutecontraindicationforthrombolytictherapyiswhat? A)

Evidenceofhemorrhagicstroke

B)

Bloodpressureof180/110mmHg

C)

Evidenceofstrokeevolution

D)

Previousthrombolytictherapywithinthepast12months

Ans:

A Feedback: Thrombolytictherapywouldexacerbateahemorrhagicstrokewithpotentiallyfatalconsequences. Strokeevolution,highBP,orpreviousthrombolytictherapydoesnotcontraindicateitssafeand effectiveuse.

17. Whencaringforapatientwhohashadastroke,apriorityisreductionofICP.Whatpatientpositionis mostconsistentwiththisgoal? A)

Headturnedslightlytotherightside

B)

Elevationoftheheadofthebed

C)

Positionchangesevery15minuteswhileawake

D)

Extensionoftheneck

Ans:

B Feedback: ElevationoftheheadofthebedpromotesvenousdrainageandlowersICP;thenurseshouldavoid flexingorextendingtheneckorturningtheheadsidetoside.Theheadshouldbeinaneutralmidline position.Excessivelyfrequentpositionchangesareunnecessary.

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

1267

18. Apatientwhosufferedanischemicstrokenowhasdisturbedsensoryperception.Whatprincipleshould guidethenursescareofthispatient? A)

Thepatientshouldbeapproachedonthesidewherevisualperceptionisintact.

B)

Attentiontotheaffectedsideshouldbeminimizedinordertodecreaseanxiety.

C)

Thepatientshouldavoidturninginthedirectionofthedefectivevisualfieldtominimizeshoulder subluxation.

D)

Thepatientshouldbeapproachedontheoppositesideofwherethevisualperceptionisintactto promoterecovery.

Ans:

A Feedback: Patientswithdecreasedfieldofvisionshouldfirstbeapproachedonthesidewherevisualperceptionis intact.Allvisualstimulishouldbeplacedonthisside.Thepatientcanandshouldbetaughttoturnthe headinthedirectionofthedefectivevisualfieldtocompensateforthisloss.Thenurseshouldconstantly remindthepatientoftheothersideofthebodyandshouldlaterstandatapositionthatencouragesthe patienttomoveorturntovisualizewhoandwhatisintheroom.

19. Whatshouldbeincludedinthepatientscareplanwhenestablishinganexerciseprogramforapatient affectedbyastroke? A)

Schedulepassiverangeofmotioneveryotherday.

B)

Keepactivitylimited,asthepatientmaybeoverstimulated.

C)

Havethepatientperformactiverange-of-motion(ROM)exercisesonceaday.

D)

Exercisetheaffectedextremitiespassivelyfourorfivetimesaday.

Ans:

D Feedback: TheaffectedextremitiesareexercisedpassivelyandputthroughafullROMfourorfivetimesadayto maintainjointmobility,regainmotorcontrol,preventdevelopmentofacontractureintheparalyzed extremity,preventfurtherdeteriorationoftheneuromuscularsystem,andenhancecirculation.Active ROMexercisesshouldideallybeperformedmorethanonceperday.

20. Afemalepatientisdiagnosedwitharight-sidedstroke.Thepatientisnowexperiencinghemianopsia. Howmightthenursehelpthepatientmanageherpotentialsensoryandperceptionaldifficulties?

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

A)

Keepthelightinginthepatientsroomlow.

B)

Placethepatientsclockontheaffectedside.

C)

Approachthepatientont...