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TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

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Chapter57:Stroke TestBank MULTIPLECHOICE 1.Afterapatientexperiencedabriefepisodeoftinnitus,diplopia,anddysarthriawithnoresidualeffects,the nurseanticipatesteachingthepatientabout a.

cerebralaneurysmclipping.

b.

heparinintravenousinfusion.

c.

orallow-doseaspirintherapy.

d.

tissueplasminogenactivator(tPA).

ANS:C Thepatientssymptomsareconsistentwithtransientischemicattack(TIA),anddrugsthatinhibitplatelet aggregationareprescribedafteraTIAtopreventstroke.Continuousheparininfusionisnotroutinelyused afterTIAorwithacuteischemicstroke.Thepatientssymptomsarenotconsistentwithacerebralaneurysm. tPAisusedonlyforacuteischemicstroke,notforTIA. DIF:CognitiveLevel:Apply(application)REF:1348 TOP:NursingProcess:PlanningMSC:NCLEX:PhysiologicalIntegrity 2.A68-year-oldpatientisbeingadmittedwithapossiblestroke.Whichinformationfromtheassessment indicatesthatthenurseshouldconsultwiththehealthcareproviderbeforegivingtheprescribedaspirin? a.

Thepatienthasdysphasia.

b.

Thepatienthasatrialfibrillation.

c.

Thepatientreportsthatsymptomsbeganwithasevereheadache.

d.

Thepatienthasahistoryofbriefepisodesofright-sidedhemiplegia.

ANS:C Asuddenonsetheadacheistypicalofasubarachnoidhemorrhage,andaspiriniscontraindicated.Atrial fibrillation,dysphasia,andtransientischemicattack(TIA)arenotcontraindicationstoaspirinuse,sothenurse canadministertheaspirin. DIF:CognitiveLevel:Apply(application)REF:1349 TOP:NursingProcess:AssessmentMSC:NCLEX:PhysiologicalIntegrity 3.A73-year-oldpatientwithastrokeexperiencesfacialdroopingontherightsideandright-sidedarmandleg paralysis.Whenadmittingthepatient,whichclinicalmanifestationwillthenurseexpecttofind?

TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

a.

Impulsivebehavior

b.

Right-sidedneglect

c.

Hyperactiveleft-sidedtendonreflexes

d.

Difficultycomprehendinginstructions

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ANS:D Right-sidedparalysisindicatesaleft-brainstroke,whichwillleadtodifficultywithcomprehensionanduseof language.Theleft-sidereflexesarelikelytobeintact.Impulsivebehaviorandneglectaremorelikelywitha right-sidestroke. DIF:CognitiveLevel:Apply(application)REF:1364 TOP:NursingProcess:AssessmentMSC:NCLEX:PhysiologicalIntegrity 4.Duringthechangeofshiftreportanurseistoldthatapatienthasanoccludedleftposteriorcerebralartery. Thenursewillanticipatethatthepatientmayhave a.

dysphasia.

b.

confusion.

c.

visualdeficits.

d.

poorjudgment.

ANS:C Visualdisturbancesareexpectedwithposteriorcerebralarteryocclusion.Aphasiaoccurswithmiddlecerebral arteryinvolvement.Cognitivedeficitsandchangesinjudgmentaremoretypicalofanteriorcerebralartery occlusion. DIF:CognitiveLevel:Apply(application)REF:1350 TOP:NursingProcess:AssessmentMSC:NCLEX:PhysiologicalIntegrity 5.Whenteachingaboutclopidogrel(Plavix),thenursewilltellthepatientwithcerebralatherosclerosis a.

tomonitorandrecordthebloodpressuredaily.

b.

thatPlavixwilldissolveclotsinthecerebralarteries.

c.

thatPlavixwillreducecerebralarteryplaqueformation.

d.

tocallthehealthcareproviderifstoolsarebloodyortarry.

TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

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ANS:D Clopidogrel(Plavix)inhibitsplateletfunctionandincreasestheriskforgastrointestinalbleeding,sopatients shouldbeadvisedtonotifythehealthcareprovideraboutanysignsofbleeding.Themedicationdoesnot lowerbloodpressure,decreaseplaqueformation,ordissolveclots. DIF:CognitiveLevel:Apply(application)REF:1355 TOP:NursingProcess:ImplementationMSC:NCLEX:PhysiologicalIntegrity 6.Apatientwithcarotidatherosclerosisasksthenursetodescribeacarotidendarterectomy.Whichresponse bythenurseisaccurate? a.

Theobstructingplaqueissurgicallyremovedfromanarteryintheneck.

b.

Thediseasedportionofthearteryinthebrainisreplacedwithasyntheticgraft.

c.

Awireisthreadedthroughanarteryinthelegtotheclotsinthecarotidarteryandtheclotsare removed.

d.

Acatheterwithadeflatedballoonispositionedatthenarrowarea,andtheballoonisinflatedto flattentheplaque.

ANS:A Inacarotidendarterectomy,thecarotidarteryisincisedandtheplaqueisremoved.Theresponsebeginning, Thediseasedportionofthearteryinthebrainisreplaceddescribesanarterialgraftprocedure.Theanswer beginning,Acatheterwithadeflatedballoonispositionedatthenarrowareadescribesanangioplasty.The finalresponsebeginning,Awireisthreadedthroughthearterydescribesthemechanicalembolusremovalin cerebralischemia(MERCI)procedure. DIF:CognitiveLevel:Understand(comprehension)REF:1354 TOP:NursingProcess:ImplementationMSC:NCLEX:PhysiologicalIntegrity 7.Apatientadmittedwithpossiblestrokehasbeenaphasicfor3hoursandhiscurrentbloodpressure(BP)is 174/94mmHg.Whichorderbythehealthcareprovidershouldthenursequestion? a.

Keepheadofbedelevatedatleast30degrees.

b.

Infusenormalsalineintravenouslyat75mL/hr.

c.

Administertissueplasminogenactivator(tPA)perprotocol.

d.

Administeralabetalol(Normodyne)driptokeepBPlessthan140/90mmHg.

ANS:D BecauseelevatedBPmaybeaprotectiveresponsetomaintaincerebralperfusion,antihypertensivetherapyis recommendedonlyifmeanarterialpressure(MAP)is>130mmHgorsystolicpressureis>220mmHg.Fluid intakeshouldbe1500to2000mLdailytomaintaincerebralbloodflow.Theheadofthebedshouldbe elevatedtoatleast30degrees,unlessthepatienthassymptomsofpoortissueperfusion.tPAmaybe

TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

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administeredifthepatientmeetstheothercriteriafortPAuse. DIF:CognitiveLevel:Apply(application)REF:1354 TOP:NursingProcess:ImplementationMSC:NCLEX:PhysiologicalIntegrity 8.A56-year-oldpatientarrivesintheemergencydepartmentwithhemiparesisanddysarthriathatstarted2 hourspreviously,andhealthrecordsshowahistoryofseveraltransientischemicattacks(TIAs).Thenurse anticipatespreparingthepatientfor a.

surgicalendarterectomy.

b.

transluminalangioplasty.

c.

intravenousheparinadministration.

d.

tissueplasminogenactivator(tPA)infusion.

ANS:D Thepatientshistoryandclinicalmanifestationssuggestanacuteischemicstrokeandapatientwhoisseen within4.5hoursofstrokeonsetislikelytoreceivetPA(afterscreeningwithaCTscan).Heparin administrationintheemergencyphaseisnotindicated.Emergentcarotidtransluminalangioplastyor endarterectomyisnotindicatedforthepatientwhoishavinganacuteischemicstroke. DIF:CognitiveLevel:Apply(application)REF:1348 TOP:NursingProcess:PlanningMSC:NCLEX:PhysiologicalIntegrity 9.Afemalepatientwhohadastroke24hoursagohasexpressiveaphasia.Thenurseidentifiesthenursing diagnosisofimpairedverbalcommunication.Anappropriatenursinginterventiontohelpthepatient communicateisto a.

askquestionsthatthepatientcananswerwithyesorno.

b.

developalistofwordsthatthepatientcanreadandpracticereciting.

c.

havethepatientpracticeherfacialandtongueexerciseswithamirror.

d.

preventembarrassingthepatientbyansweringforherifshedoesnotrespond.

ANS:A Communicationwillbefacilitatedandlessfrustratingtothepatientwhenquestionsthatrequireayesorno responseareused.Whenthelanguageareasofthebrainareinjured,thepatientmightnotbeabletoreador recitewords,whichwillfrustratethepatientwithoutimprovingcommunication.Expressiveaphasiaiscaused bydamagetothelanguageareasofthebrain,notbytheareasthatcontrolthemotoraspectsofspeech.The nurseshouldallowtimeforthepatienttorespond. DIF:CognitiveLevel:Apply(application)REF:1364 TOP:NursingProcess:ImplementationMSC:NCLEX:PhysiologicalIntegrity

TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

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10.Forapatientwhohadarighthemispherestrokethenurseestablishesanursingdiagnosisof a.

riskforinjuryrelatedtodenialofdeficitsandimpulsiveness.

b.

impairedphysicalmobilityrelatedtoright-sidedhemiplegia.

c.

impairedverbalcommunicationrelatedtospeech-languagedeficits.

d.

ineffectivecopingrelatedtodepressionanddistressaboutdisability.

ANS:A Thepatientwithright-sidedbraindamagetypicallydeniesanydeficitsandhaspoorimpulsecontrol,leadingto riskforinjurywhenthepatientattemptsactivitiessuchastransferringfromabedtoachair.Right-sidedbrain damagecauseslefthemiplegia.Left-sidedbraindamagetypicallycauseslanguagedeficits.Left-sidedbrain damageisassociatedwithdepressionanddistressaboutthedisability. DIF:CognitiveLevel:Apply(application)REF:1364 TOP:NursingProcess:DiagnosisMSC:NCLEX:PhysiologicalIntegrity 11.Whencaringforapatientwithanewright-sidedhomonymoushemianopsiaresultingfromastroke,which interventionshouldthenurseincludeintheplanofcare? a.

Applyaneyepatchtotherighteye.

b.

Approachthepatientfromtherightside.

c.

Placeobjectsneededonthepatientsleftside.

d.

Teachthepatientthattheleftvisualdeficitwillresolve.

ANS:C Duringtheacuteperiod,thenurseshouldplaceobjectsonthepatientsunaffectedside.Becausethereisa visualdefectintherighthalfofeacheye,aneyepatchisnotappropriate.Thepatientshouldbeapproached fromtheleftside.Thevisualdeficitmaynotresolve,althoughthepatientcanlearntocompensateforthe defect. DIF:CognitiveLevel:Apply(application)REF:1364 TOP:NursingProcess:PlanningMSC:NCLEX:PhysiologicalIntegrity 12.Thenurseidentifiesthenursingdiagnosisofimbalancednutrition:lessthanbodyrequirementsrelatedto impairedself-feedingabilityforaleft-handedpatientwithleft-sidedhemiplegia.Whichinterventionshouldbe includedintheplanofcare? a.

Provideawidevarietyoffoodchoices.

b.

Provideoralcarebeforeandaftermeals.

TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

c.

Assistthepatienttoeatwiththerighthand.

d.

Teachthepatientthechin-tucktechnique.

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ANS:C Becausethenursingdiagnosisindicatesthatthepatientsimbalancednutritionisrelatedtotheleft-sided hemiplegia,theappropriateinterventionswillfocusonteachingthepatienttousetherighthandforselffeeding.Theotherinterventionsareappropriateforpatientswithotheretiologiesfortheimbalancednutrition. DIF:CognitiveLevel:Apply(application)REF:1364 TOP:NursingProcess:PlanningMSC:NCLEX:PhysiologicalIntegrity 13.A40-year-oldpatienthasarupturedcerebralaneurysmandsubarachnoidhemorrhage.Whichintervention willbeincludedinthecareplan? a.

Applyintermittentpneumaticcompressionstockings.

b.

Assisttodangleonedgeofbedandassessfordizziness.

c.

Encouragepatienttocoughanddeepbreatheevery4hours.

d.

Insertanoropharyngealairwaytopreventairwayobstruction.

ANS:A Thepatientwithasubarachnoidhemorrhageusuallyhasminimalactivitytopreventcerebralvasospasmor furtherbleedingandisatriskforvenousthromboembolism(VTE).Activitiessuchascoughingandsittingup thatmightincreaseintracranialpressure(ICP)ordecreasecerebralbloodflowareavoided.Becausethereisno indicationthatthepatientisunconscious,anoropharyngealairwayisinappropriate. DIF:CognitiveLevel:Apply(application)REF:1362 TOP:NursingProcess:PlanningMSC:NCLEX:PhysiologicalIntegrity 14.A47-year-oldpatientwillattemptoralfeedingsforthefirsttimesincehavingastroke.Thenurseshould assessthegagreflexandthen a.

orderavariedpureeddiet.

b.

assessthepatientsappetite.

c.

assistthepatientintoachair.

d.

offerthepatientasipofjuice.

ANS:C Thepatientshouldbeasuprightaspossiblebeforeattemptingfeedingtomakeswallowingeasieranddecrease

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aspirationrisk.Toassessswallowingability,thenurseshouldinitiallyofferwateroricetothepatient.Pureed dietsarenotrecommendedbecausethetextureistoosmooth.Thepatientmayhaveapoorappetite,butthe oralfeedingshouldbeattemptedregardless. DIF:CognitiveLevel:Apply(application)REF:1363 TOP:NursingProcess:ImplementationMSC:NCLEX:PhysiologicalIntegrity 15.Amalepatientwhohasright-sidedweaknessafterastrokeismakingprogressinlearningtousetheleft handforfeedingandotheractivities.Thenurseobservesthatwhenthepatientswifeisvisiting,shefeedsand dresseshim.Whichnursingdiagnosisismostappropriateforthepatient? a.

Interruptedfamilyprocessesrelatedtoeffectsofillnessofafamilymember

b.

Situationallowself-esteemrelatedtoincreasingdependenceonspouseforcare

c.

Disabledfamilycopingrelatedtoinadequateunderstandingbypatientsspouse

d.

Impairednutrition:lessthanbodyrequirementsrelatedtohemiplegiaandaphasia

ANS:C Theinformationsupportsthediagnosisofdisabledfamilycopingbecausethewifedoesnotunderstandthe rehabilitationprogram.Therearenodatasupportinglowself-esteem,andthepatientisattempting independence.Thedatadonotsupportaninterruptioninfamilyprocessesbecausethismaybeatypical patternforthecouple.Thereisnoindicationthatthepatienthasimpairednutrition. DIF:CognitiveLevel:Apply(application)REF:1366 TOP:NursingProcess:DiagnosisMSC:NCLEX:PsychosocialIntegrity 16.Severalweeksafterastroke,a50-year-oldmalepatienthasimpairedawarenessofbladderfullness, resultinginurinaryincontinence.Whichnursinginterventionwillbebesttoincludeintheinitialplanforan effectivebladdertrainingprogram? a.

Limitfluidintaketo1200mLdailytoreduceurinevolume.

b.

Assistthepatientontothebedsidecommodeevery2hours.

c.

Performintermittentcatheterizationaftereachvoidingtocheckforresidualurine.

d.

Useanexternalcondomcathetertoprotecttheskinandpreventembarrassment.

ANS:B Developingaregularvoidingschedulewillpreventincontinenceandmayincreasepatientawarenessofafull bladder.A1200mLfluidrestrictionmayleadtodehydration.Intermittentcatheterizationanduseofacondom catheterareappropriateintheacutephaseofstroke,butshouldnotbeconsideredsolutionsforlong-term managementbecauseoftherisksforurinarytractinfection(UTI)andskinbreakdown. DIF:CognitiveLevel:Apply(application)REF:1363

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TOP:NursingProcess:PlanningMSC:NCLEX:PhysiologicalIntegrity 17.A72-year-oldpatientwhohasahistoryofatransientischemicattack(TIA)hasanorderforaspirin160 mgdaily.Whenthenurseisadministeringmedications,thepatientsays,Idontneedtheaspirintoday.Idont haveafever.Whichactionshouldthenursetake? a.

Documentthattheaspirinwasrefusedbythepatient.

b.

Tellthepatientthattheaspirinisusedtopreventafever.

c.

Explainthattheaspirinisorderedtodecreasestrokerisk.

d.

Callthehealthcareprovidertoclarifythemedicationorder.

ANS:C AspirinisorderedtopreventstrokeinpatientswhohaveexperiencedTIAs.Documentationofthepatients refusaltotakethemedicationisaninadequateresponsebythenurse.Thereisnoneedtoclarifytheorderwith thehealthcareprovider.Theaspirinisnotorderedtopreventachesandpains. DIF:CognitiveLevel:Apply(application)REF:1353 TOP:NursingProcess:ImplementationMSC:NCLEX:PhysiologicalIntegrity 18.Apatientintheclinicreportsarecentepisodeofdysphasiaandleft-sidedweaknessathomethatresolved after2hours.Thenursewillanticipateteachingthepatientabout a.

alteplase(tPA).

b.

aspirin(Ecotrin).

c.

warfarin(Coumadin).

d.

nimodipine(Nimotop).

ANS:B Followingatransientischemicattack(TIA),patientstypicallyarestartedonmedicationssuchasaspirinto inhibitplateletfunctionanddecreasestrokerisk.tPAisusedforacuteischemicstroke.Coumadinisusually usedforpatientswithatrialfibrillation.Nimodipineisusedtopreventcerebralvasospasmafterasubarachnoid hemorrhage. DIF:CognitiveLevel:Apply(application)REF:1353 TOP:NursingProcess:PlanningMSC:NCLEX:PhysiologicalIntegrity 19.A58-year-oldpatientwithaleft-brainstrokesuddenlyburstsintotearswhenfamilymembersvisit.The nurseshould a.

useacalmvoicetoaskthepatienttostopthecryingbehavior.

TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

b.

explaintothefamilythatdepressionisnormalfollowingastroke.

c.

havethefamilymembersleavethepatientaloneforafewminutes.

d.

teachthefamilythatemotionaloutburstsarecommonafterstrokes.

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ANS:D Patientswhohaveleft-sidedbrainstrokearepronetoemotionaloutburststhatarenotnecessarilyrelatedtothe emotionalstateofthepatient.Depressionafterastrokeiscommon,butthesuddennessofthepatientsoutburst suggeststhatdepressionisnotthemajorcauseofthebehavior.Thefamilyshouldstaywiththepatient.The cryingisnotwithinthepatientscontrolandaskingthepatienttostopwillleadtoembarrassment. DIF:CognitiveLevel:Apply(application)REF:1366 TOP:NursingProcess:ImplementationMSC:NCLEX:PsychosocialIntegrity 20.Whichstrokeriskfactorfora48-year-oldmalepatientintheclinicismostimportantforthenurseto address? a.