Cerebrovascular Accident (Medical Surgical Nursing)

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Cerebrovascular Accident (Medical Surgical Nursing)

Cerebrovascular Accident The sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain. A CVA is also referred to as a stroke. Symptoms of a stroke depend on the area of the brain affected. The most common symptom is weakness or paralysis of one side of the body with partial or complete loss of voluntary movement or sensation in a leg or arm. There can be speech problems and weak face muscles, causing drooling. Numbness or tingling is very common. A stroke involving the base of the brain can affect balance, vision, swallowing, breathing and even unconsciousness.


Questions and Answers
  • 1. 
    A 78-year-old client is admitted to the emergency department with numbness and weak- ness of the left arm and slurred speech. Which nursing intervention is priority?
    • A. 

      Prepare to administer recombinant tissue plasminogen activator (rt-PA).

    • B. 

      Discuss the precipitating factors that caused the symptoms.

    • C. 

      Schedule for a STAT computed tomography (CT) scan of head.

    • D. 

      Notify the speech pathologist for an emergency consult.

  • 2. 
    The nurse is assessing a client experiencing motor loss as a result of a left-sided cere- brovascular accident (CVA). Which clinical manifestations would the nurse document? 
    • A. 

      Hemiparesis of the client’s left arm and apraxia.

    • B. 

      Paralysis of the right side of the body and ataxia.

    • C. 

      Homonymous hemianopsia and diplopia.

    • D. 

      Impulsive behavior and hostility toward family.

  • 3. 
    Which client would the nurse identify as being most at risk for experiencing a CVA?    
    • A. 

      A 55-year-old African American male.

    • B. 

      An 84-year-old Japanese female.

    • C. 

      A 67-year-old Caucasian male.

    • D. 

      A 39-year-old pregnant female.

  • 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.
    • A. 

      Position the client to prevent shoulder adduction.

    • B. 

      Turn and reposition the client every shift.

    • C. 

      Encourage the client to move the affected side.

    • D. 

      Perform quadriceps exercises three (3) times a day.

    • E. 

      Instruct the client to hold the fingers in a fist.

  • 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? 
    • A. 

      Observing the client swallowing for possible aspiration.

    • B. 

      Positioning the client in a semi-Fowler’s position when sleeping.

    • C. 

      Placing a suction set-up at the client’s bedside during meals.

    • D. 

      Referring the client to an occupational therapist for evaluation.

  • 6. 
    • A. 

      The assistant places a gait belt around the client’s waist prior to ambulating.

    • B. 

      The assistant places the client on the back with the client’s head to the side.

    • C. 

      The assistant places her hand under the client’s right axilla to help him/her move up in bed.

    • D. 

      The assistant praises the client for attempting to perform ADLs independently.

  • 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?
    • A. 

      An oral anticoagulant medication.

    • B. 

      A beta-blocker medication.

    • C. 

      An anti-hyperuricemic medication.

    • D. 

      A thrombolytic medication.

  • 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?
    • A. 

      Obtain a rubber mat to place under the dinner plate.

    • B. 

      Purchase a long-handled bath sponge for showering.

    • C. 

      Purchase clothes with Velcro closure devices.

    • D. 

      Obtain a raised toilet seat for the client’s bathroom.

  • 9. 
    The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the plan of care?
    • A. 

      Potential for injury.

    • B. 

      Powerlessness.

    • C. 

      Disturbed thought processes.

    • D. 

      Sexual dysfunction.

  • 10. 
    • A. 

      A blood glucose level of 480 mg/dL.

    • B. 

      A right-sided carotid bruit.

    • C. 

      A blood pressure of 220/120 mm Hg.

    • D. 

      The presence of bronchogenic carcinoma.

  • 11. 
    The 85-year-old client diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first?
    • A. 

      Administer a nonnarcotic analgesic.

    • B. 

      Prepare for STAT magnetic resonance imaging (MRI).

    • C. 

      Start an intravenous line with D5W at 100 mL/hr.

    • D. 

      Complete a neurological assessment.

  • 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?
    • A. 

      Administer a stool softener BID.

    • B. 

      Encourage the client to cough hourly.

    • C. 

      Monitor neurological status every shift.

    • D. 

      Maintain the dopamine drip to keep BP at 160/90.