1.
A 78-year-old client was admitted to the emergency department with numbness and weakness in the left arm and slurred speech. Which nursing intervention is a priority?
Correct Answer
C. Schedule for a STAT computed tomography (CT) scan of the head
Explanation
The priority nursing intervention in this case is to schedule for a STAT computed tomography (CT) scan of the head. This is because the client is presenting with symptoms that are indicative of a possible stroke, such as numbness, weakness, and slurred speech. A CT scan of the head can help to determine if there is bleeding or a clot in the brain, which will guide further treatment decisions. Administering rt-PA, discussing precipitating factors, and notifying a speech pathologist may be appropriate interventions, but they are not the priority in this situation.
2.
The nurse is assessing a client experiencing motor loss as a result of a left-sided cerebrovascular accident (CVA). Which clinical manifestations would the nurse document?
Correct Answer
B. Paralysis of the right side of the body and ataxia
Explanation
The nurse would document paralysis of the right side of the body and ataxia as clinical manifestations of a left-sided cerebrovascular accident (CVA). Paralysis of the right side of the body is a common symptom of a CVA affecting the left side of the brain, as the left side of the brain controls the right side of the body. Ataxia, which refers to uncoordinated or unsteady movements, can also occur as a result of a CVA.
3.
Which client would the nurse identify as being most at risk for experiencing a CVA?
Correct Answer
A. A 55-year-old African American male
Explanation
African Americans have a higher risk for experiencing a CVA (cerebrovascular accident) compared to other ethnic groups. This is due to various factors such as higher prevalence of hypertension, diabetes, and obesity in this population. Age is also a risk factor for CVA, and being 55 years old puts this client at a higher risk. Therefore, the nurse would identify the 55-year-old African American male as being most at risk for experiencing a CVA.
4.
The client, diagnosed with a right-sided cerebrovascular accident, is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply.
Correct Answer(s)
A. Position the client to prevent shoulder adduction
C. Encourage the client to move the affected side
Explanation
The client with a right-sided cerebrovascular accident is at risk for shoulder adduction, which can lead to shoulder pain and decreased range of motion. Positioning the client to prevent shoulder adduction helps maintain proper alignment and prevents complications. Encouraging the client to move the affected side promotes muscle strength and range of motion. Turning and repositioning the client every shift helps prevent pressure ulcers. Performing quadriceps exercises three times a day helps maintain muscle strength and prevent muscle atrophy. Instructing the client to hold the fingers in a fist helps prevent finger contractures.
5.
The nurse is planning care for a client experiencing agnosia secondary to a cerebrovascular accident. Which collaborative intervention will be included in the plan of care?
Correct Answer
D. Referring the client to an occupational therapist for evaluation
Explanation
The nurse plans to include referring the client to an occupational therapist for evaluation in the care plan because agnosia is a condition that affects the client's ability to recognize and interpret sensory information. An occupational therapist can assess the client's functional abilities and develop strategies to help them adapt and compensate for their deficits. This intervention is important in promoting the client's independence and improving their quality of life.
6.
The nurse and an unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene?
Correct Answer
C. The assistant places her hand under the client’s right axilla to help him/her move up in bed.
Explanation
Placing the hand under the client's right axilla to help them move up in bed is an incorrect action by the UAP. This can potentially cause harm to the client with right-sided paralysis as it can lead to injury or discomfort. The nurse should intervene and educate the UAP on the appropriate technique for assisting the client in bed mobility.
7.
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?
Correct Answer
A. An oral anticoagulant medication
Explanation
The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA), which is a warning sign of a possible stroke. Atrial fibrillation increases the risk of blood clots forming in the heart, which can then travel to the brain and cause a stroke. Therefore, the nurse would anticipate an oral anticoagulant medication to be ordered for the client on discharge. Anticoagulants help prevent blood clots from forming and reduce the risk of stroke in individuals with atrial fibrillation.
8.
The client has been diagnosed with a cerebrovascular accident (stroke). The client’s wife is concerned about her husband’s generalized weakness. Which home modification should the nurse suggest to the wife prior to discharge?
Correct Answer
D. Obtain a raised toilet seat for the client’s bathroom
Explanation
A cerebrovascular accident (stroke) can cause weakness and difficulty with mobility. A raised toilet seat can make it easier for the client to sit down and stand up from the toilet, reducing the risk of falls and promoting independence. This modification can enhance safety and accessibility in the bathroom for the client.
9.
The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the plan of care?
Correct Answer
B. Powerlessness
Explanation
The nurse would include the psychosocial client problem of powerlessness in the plan of care because expressive aphasia can cause difficulty in communication and expressing oneself effectively. This can lead to feelings of powerlessness and frustration for the client. Including powerlessness in the plan of care would address the client's emotional and psychological needs, and help provide support and strategies to cope with the challenges of expressive aphasia.
10.
Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke?
Correct Answer
C. A blood pressure of 220/120 mm Hg
Explanation
A blood pressure of 220/120 mm Hg would indicate that the client is at risk for a hemorrhagic stroke. High blood pressure, especially when it is severely elevated like in this case, can cause damage to the blood vessels in the brain, leading to a hemorrhagic stroke. Hemorrhagic strokes occur when a blood vessel in the brain ruptures and causes bleeding. Therefore, the high blood pressure reading suggests that the client's blood vessels may be weakened and at risk for rupture, increasing the likelihood of a hemorrhagic stroke.
11.
The 85-year-old client diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first?
Correct Answer
D. Complete a neurological assessment
Explanation
The correct answer is to complete a neurological assessment. When a client with a stroke complains of a severe headache, it is important to assess their neurological status first. This assessment can help determine the severity of the stroke and identify any potential complications or changes in the client's condition. Administering a nonnarcotic analgesic may provide temporary relief for the headache, but it does not address the underlying cause. Preparing for a STAT MRI and starting an intravenous line may be necessary interventions, but they should be implemented after completing the neurological assessment to ensure appropriate and timely care.
12.
A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement?
Correct Answer
A. Administer a stool softener BID
Explanation
The client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. After a craniotomy, the client may experience constipation due to the effects of anesthesia, immobility, and pain medications. Administering a stool softener twice a day will help prevent constipation and promote regular bowel movements. This intervention is important to ensure the client's comfort and prevent complications such as straining, which can increase intracranial pressure.