The nurse is caring for a patient with a history of transient ischemic attacks (TIAs) and moderate carotid stenosis who has undergone a carotid endarterectomy. Which of the following postoperative findings would cause the nurse the most concern?
a) Blood pressure (BP): 128/86 mm Hg
b) Neck pain: 3/10 (0 to 10 pain scale)
c) Mild neck edema
d) Difficulty swallowing
answer
Difficulty swallowing
The patient's inability to swallow without difficulty would cause the nurse the most concern. Difficulty in swallowing, hoarseness or other signs of cranial nerve dysfunction must be assessed. The nurse focuses on assessment of the following cranial nerves: facial (VII), vagus (X), spinal accessory (XI), and hypoglossal (XII). Some edema in the neck after surgery is expected; however, extensive edema and hematoma formation can obstruct the airway. Emergency airway supplies, including those needed for a tracheostomy, must be available. The patient's neck pain and mild BP elevation need addressing but would not cause the nurse the most concern. Hypotension is avoided to prevent cerebral ischemia and thrombosis. Uncontrolled hypertension may precipitate cerebral hemorrhage, edema, hemorrhage at the surgical incision, or disruption of the arterial reconstruction.
question
An emergency department nurse is interviewing a client with signs of an ischemic stroke that began 2 hours ago. The client reports that she had a cholecystectomy 6 weeks ago and is taking digoxin, coumadin, and labetelol. This client is not eligible for thrombolytic therapy for which of the following reasons?
a) She is not within the treatment time window.
b) She had surgery 6 weeks ago.
c) She is taking digoxin.
d) She is taking coumadin.
answer
She is taking coumadin.
To be eligible for thrombolytic therapy, the client cannot be taking coumadin. Initiation of thrombolytic therapy must be within 3 hours in clients with ischemic stroke. The client is not eligible for thrombolytic therapy if she has had surgery within 14 days. Digoxin and labetelol do not prohibit thrombolytic therapy.
question
Which disturbance results in loss of half of the visual field?
a) Anisocoria
b) Homonymous hemianopsia
c) Nystagmus
d) Diplopia
answer
Homonymous hemianopsia
Homonymous hemianopsia (loss of half of the visual field) may occur from stroke and may be temporary or permanent. Double vision is documented as diplopia. Nystagmus is ocular bobbing and may be seen in multiple sclerosis. Anisocoria is unequal pupils.
question
A client with a cerebrovascular accident (CVA) is having difficulty with eating food on the plate. Which is the best nursing action to be taken?
a) Reposition the tray and plate.
b) Perform a vision field assessment.
c) Know this is a normal finding for CVA.
d) Assist the client with feeding.
answer
Perform a vision field assessment.
The nurse should perform a vision field assessment to evaluate the client forhemianopia. This finding could indicate damage to the visual area of the brain as a result of evolving CVA. Repositioning the tray and assisting with feeding would not be the best nursing action until new finding has been evaluated. Hemianopia can be associated with a CVA but, when presenting as a new finding, should be evaluated and reported immediately. (less)
question
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) Cerebral aneurysm
b) Transient ischemic attack
c) Left-sided stroke
d) Right-sided stroke
answer
Transient ischemic attack
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.
question
Which of the following terms refer to the failure to recognize familiar objects perceived by the senses?
a) Agnosia
b) Perseveration
c) Apraxia
d) Agraphia
answer
Agnosia
Auditory agnosia is failure to recognize significance of sounds. Agraphia refers to disturbances in writing intelligible words. Apraxia refers to inability to perform previously learned purposeful motor acts on a voluntary basis. Perseveration is the continued and automatic repetition of an activity, word, or phrase that is no longer appropriate.
question
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 generally include aphasia, one-sided flaccidity, and trouble swallowing."
c) "Clinical manifestations of a stroke depend on how quickly the clot can be dissolved."
d) "Clinical manifestations of a stroke are highly variable, depending on the cardiovascular health of the client."
answer
"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."
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.
question
When communicating with a client who has sensory (receptive) aphasia, the nurse should:
a) speak loudly and articulate clearly.
b) allow time for the client to respond.
c) give the client a writing pad.
d) use short, simple sentences.
answer
use short, simple sentences.
Although sensory aphasia allows the client to hear words, it impairs the ability to comprehend their meaning. The nurse should use short, simple sentences to promote comprehension. Allowing time for the client to respond might be helpful but is less important than simplifying the communication. Because the client's hearing isn't affected, speaking loudly isn't necessary. A writing pad is helpful for clients with expressive, not receptive, aphasia.
question
The nurse is providing information about strokes to a community group. Which of the following would the nurse identify as the primary initial symptoms of an ischemic stroke?
a) Footdrop and external hip rotation
b) Vomiting and seizures
c) Severe headache and early change in level of consciousness
d) Weakness on one side of the body and difficulty with speech
answer
Weakness on one side of the body and difficulty with speech
The main presenting symptoms for an ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body; confusion or change in mental status; and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Footdrop and external hip rotation are things that can occur if a stroke victim is not turned or positioned correctly.
question
Which of the following insults or abnormalities can cause an ischemic stroke?
a) Arteriovenous malformation
b) Intracerebral aneurysm rupture
c) Cocaine use
d) Trauma
answer
Cocaine use
Cocaine is a potent vasoconstrictor and may result in a life-threatening reaction, even with the individual's first use of the drug. Arteriovenous malformations are associated with hemorrhagic strokes. Trauma is associated with hemorrhagic strokes. Intracerebral aneurysm rupture is associated with hemorrhagic strokes.
question
A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention?
a) Maintaining the client in a quiet environment
b) Keeping the client in one position to decrease bleeding
c) Positioning the client to prevent airway obstruction
d) Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess
answer
Keeping the client in one position to decrease bleeding
The student nurse shouldn't keep the client in one position. She should carefully reposition the client often (at least every hour). The client needs to be positioned so that a patent airway can be maintained. Fluid administration must be closely monitored to prevent complications such as increased intracranial pressure. The client must be maintained in a quiet environment to decrease the risk of rebleeding.
question
The nurse is caring for a patient with aphasia. Which of the following strategies will the nurse use to facilitate communication with the patient?
a) Speaking in complete sentences
b) Speaking loudly
c) Avoiding the use of hand gestures
d) Establishing eye contact
answer
Establishing eye contact
The following strategies should be used by the nurse to encourage communication with a patient with aphasia: face the patient and establish eye contact, speak in your usual manner and tone, use short phrases, and pause between phrases to allow the patient time to understand what is being said; limit conversation to practical and concrete matters; use gestures, pictures, objects, and writing; and as the patient uses and handles an object, say what the object is. It helps to match the words with the object or action, be consistent in using the same words and gestures each time you give instructions or ask a question, and keep extraneous noises and sounds to a minimum. Too much background noise can distract the patient or make it difficult to sort out the message being spoken. (less)
question
While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are:
a) Footdrop and external hip rotation
b) Severe headache and early change in level of consciousness
c) Weakness on one side of the body and difficulty with speech
d) Confusion or change in mental status
answer
Severe headache and early change in level of consciousness
The main presenting symptoms for ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body, confusion or change in mental status, and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Footdrop and external hip rotation can occur if a stroke victim is not turned or positioned correctly. (less)
question
A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings?
a) Left-sided cerebrovascular accident (CVA)
b) Right-sided cerebrovascular accident (CVA)
c) Transient ischemic attack (TIA)
d) Completed Stroke
answer
Left-sided cerebrovascular accident (CVA)
When the infarct is on the left side of the brain, the symptoms are likely to be on the right, and the speech is more likely to be involved. If the MRI reveals an infarct, TIA is no longer the diagnosis. There is not enough information to determine if the stroke is still evolving or is complete.
question
A nurse is caring for a client who has returned to his room after a carotid endarterectomy. Which action should the nurse take first?
a) Take the client's blood pressure.
b) Ask the client if he has a headache.
c) Ask the client if he has trouble breathing.
d) Place antiembolism stockings on the client.
answer
Ask the client if he has trouble breathing.
The nurse should first assess the client's breathing. A complication of a carotid endarterectomy is an incisional hematoma, which could compress the trachea causing breathing difficulty for the client. Although the other measures are important actions, they aren't the nurse's top priority.
question
The nurse is caring for a patient with dysphagia. Which of the following interventions would be contraindicated while caring for this patient?
a) Allowing ample time to eat
b) Assisting the patient with meals
c) Testing the gag reflex prior to offering food or fluids
d) Placing food on the affected side of mouth
answer
Placing food on the affected side of mouth
Interventions for dysphagia include placing food on the unaffected side of the mouth, allowing ample time to eat, assisting the patient with meals, and testing the patient's gag reflex prior to offering food or fluids.
question
A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the physician in the emergency department. After completing ordered diagnostic tests, the physician indicates to the client what caused the symptoms that brought him to the hospital. What is the origin of the client's symptoms?
a) Hypertension
b) Cardiac disease
c) Diabetes insipidus
d) Impaired cerebral circulation
answer
Impaired cerebral circulation
TIAs result from impaired blood circulation in the brain, which can be caused by atherosclerosis and arteriosclerosis, cardiac disease, or diabetes. The symptoms of a TIA are the result of impaired blood circulation in the brain, which may have been caused by cardiac disease. The symptoms of a TIA are the result of impaired blood circulation in the brain, which may have been caused by diabetes. The symptoms of a TIA are the result of impaired blood circulation in the brain, which may have been caused by hypertension.
question
A client is admitted to the intensive care unit (ICU) with a diagnosis of cerebrovascular accident (CVA). Which assessment by the nurse provides the most significant finding in differentiating between ischemic and hemorrhagic strokes?
a) Oropharyngeal suctioning as needed.
b) Kepprais ordered for treatment of focal seizures.
c) A unit of fresh frozen plasma is infusing.
d) Neurological checks are ordered every 2 hours.
answer
A unit of fresh frozen plasma is infusing.
FFP is usedin the treatment of clotting deficiencies as seen with over dose of anticoagulants and would indicate a hemorrhagic stroke. Neuro checks ordered every 2 hours does not differentiate between types of strokes. Focal seizures can occur with any stroke and would not differentiate. Suctioning is a nursing action taken to maintain airway and does not indicate a specific type of stroke.
question
The nurse is caring for a patient with aphasia. Which of the following strategies will the nurse use to facilitate communication with the patient?
a) Avoiding the use of hand gestures
b) Establishing eye contact
c) Speaking in complete sentences
d) Speaking loudly
answer
Establishing eye contact
The following strategies should be used by the nurse to encourage communication with a patient with aphasia: face the patient and establish eye contact, speak in your usual manner and tone, use short phrases, and pause between phrases to allow the patient time to understand what is being said; limit conversation to practical and concrete matters; use gestures, pictures, objects, and writing; and as the patient uses and handles an object, say what the object is. It helps to match the words with the object or action, be consistent in using the same words and gestures each time you give instructions or ask a question, and keep extraneous noises and sounds to a minimum. Too much background noise can distract the patient or make it difficult to sort out the message being spoken. (less)
question
The provider diagnoses the patient as having had an ischemic stroke. The etiology of an ischemic stroke would include which of the following?
a) Cerebral aneurysm
b) Cardiogenic emboli
c) Intracerebral hemorrhage
d) Arteriovenous malformation
answer
Cardiogenic emboli
Aneurysms, hemorrhages, and malformations are all examples of a hemorrhagic stroke. An embolism can block blood flow, leading to ischemia.
question
A patient is in the acute phase of an ischemic stroke. How long does the nurse know that this phase may last?
a) Up to 1 week
b) Up to 24 hours
c) 1 to 3 days
d) Up to 2 weeks
answer
1 to 3 days
The acute phase of an ischemic stroke may last 1 to 3 days, but ongoing monitoring of all body systems is essential as long as the patient requires care.
question
Which of the following terms refer to the inability to perform previously learned purposeful motor acts on a voluntary basis?
a) Agraphia
b) Perseveration
c) Agnosia
d) Apraxia
answer
Apraxia
Verbal apraxia refers to difficulty in forming and organizing intelligible words although the musculature is intact. Agnosia is failure to recognize familiar objects perceived by the senses. Agraphia refers to disturbances in writing intelligible words. Perseveration is the continued and automatic repetition of an activity or word or phrase that is no longer appropriate. (less)
question
A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention?
a) Maintaining the client in a quiet environment
b) Positioning the client to prevent airway obstruction
c) Keeping the client in one position to decrease bleeding
d) Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess
answer
Keeping the client in one position to decrease bleeding
The student nurse shouldn't keep the client in one position. She should carefully reposition the client often (at least every hour). The client needs to be positioned so that a patent airway can be maintained. Fluid administration must be closely monitored to prevent complications such as increased intracranial pressure. The client must be maintained in a quiet environment to decrease the risk of rebleeding.
question
A client has experienced an ischemic stroke that has damaged the lower motor neurons of the brain. Which of the following deficits would the nurse expect during assessment?
a) Limited attention span and forgetfulness
b) Visual agnosia
c) Auditory agnosia
d) Lack of deep tendon reflexes
answer
Lack of deep tendon reflexes
Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia. If damage has occurred to the frontal lobe, learning capacity, memory, or other higher cortical intellectual functions may be impaired. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and lack of motivation. Damage to the lower motor neurons may cause decreased muscle tone, flaccid muscle paralysis, and a decrease in or loss of reflexes.
question
A nurse knows that, for a patient with an ischemic stroke, tPA is contraindicated if the blood pressure reading is:
a) 170 mm Hg/105 mm Hg
b) 185 mm Hg/110 mm Hg
c) 190 mm Hg/120 mm Hg
d) 175 mm Hg/100 mm Hg
answer
190 mm Hg/120 mm Hg
Elevated blood pressure (systolic >185; diastolic >110 mm Hg) is a contraindication to tPA.
question
A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem?
a) Pregabalin (Lyrica)
b) Diphenhydramine (Benadryl)
c) Heparin
d) Lioresal (Baclofen)
answer
Lioresal (Baclofen)
Spasticity, particularly in the hand, can be a disabling complication after stroke. Botulinum toxin type A injected intramuscularly into wrist and finger muscles has been shown to be effective in reducing this spasticity (although the effect is temporary, typically lasting 2 to 4 months) (Teasell, Foley, Pereira, et al., 2012). Other treatments for spasticity may include stretching, splinting, and oral medications such as baclofen (Lioresal). (less)
question
A patient diagnosed with a stroke is ordered to receive warfarin (Coumadin). Later, the nurse learns that the warfarin is contraindicated and the order is canceled. The nurse knows that the best alternative medication to give is which of the following?
a) Ticlodipine (Ticlid)
b) Dipyridamole (Persantine)
c) Clopidogrel (Plavix)
d) Aspirin
answer
Aspirin
If warfarin is contraindicated, aspirin is the best option, although other medications may be used if both are contraindicated.
question
Which of the following is the most common side effect of tissue plasminogen activator (tPA)?
a) Increased intracranial pressure (ICP)
b) Hypertension
c) Headache
d) Bleeding
answer
Bleeding
Bleeding is the most common side effect of tPA. The patient is closely monitored for bleeding (at IV insertion sites, gums, urine/stools, and intracranially by assessing changes in level of consciousness). Headache, increased ICP, and hypertension are not side effects of tPA.
question
Which of the following antiseizure medication has been found to be effective for post-stroke pain?
a) Carbamazepine (Tegretol)
b) Lamotrigine (Lamictal)
c) Topiramate (Topamax)
d) Phenytoin (Dilantin)
answer
Lamotrigine (Lamictal)
The antiseizure medication lamotrigine (Lamictal) has been found to be effective for post-stroke pain.
question
The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regime, to maintain a healthy weight, and to adopt a reasonable exercise program. This advice is based on research data that shows the most important risk factor for stroke is:
a) Dyslipidemia
b) Obesity
c) Hypertension
d) Smoking
answer
Hypertension
Hypertension is the most modifiable risk factor for either ischemic or hemorrhagic stroke. Unfortunately, it remains under-recognized and undertreated in most communities.
question
While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are:
a) Footdrop and external hip rotation
b) Severe headache and early change in level of consciousness
c) Confusion or change in mental status
d) Weakness on one side of the body and difficulty with speech
answer
Severe headache and early change in level of consciousness
The main presenting symptoms for ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body, confusion or change in mental status, and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Footdrop and external hip rotation can occur if a stroke victim is not turned or positioned correctly. (less)
question
A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings?
a) Left-sided cerebrovascular accident (CVA)
b) Completed Stroke
c) Transient ischemic attack (TIA)
d) Right-sided cerebrovascular accident (CVA)
answer
Left-sided cerebrovascular accident (CVA)
When the infarct is on the left side of the brain, the symptoms are likely to be on the right, and the speech is more likely to be involved. If the MRI reveals an infarct, TIA is no longer the diagnosis. There is not enough information to determine if the stroke is still evolving or is complete.
question
A physician orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question?
a) Phenytoin (Dilantin)
b) Methyldopa (Aldomet)
c) Heparin sodium
d) Dexamethasone (Decadron)
answer
Heparin sodium
Administering heparin, an anticoagulant, could increase the bleeding associated with hemorrhagic stroke. Therefore, the nurse should question this order to prevent additional hemorrhage in the brain. In a client with hemorrhagic stroke, the physician may use dexamethasone to decrease cerebral edema and pressure; methyldopa, to reduce blood pressure; and phenytoin, to prevent seizures.
question
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) Cerebral aneurysm
b) Cardiogenic emboli
c) Large artery thrombosis
d) Small artery thrombosis
answer
Cerebral aneurysm
A cerebral aneurysm is a type of hemorrhagic stroke that is characterized by an exploding headache.
question
Which of the following is accurate regarding a hemorrhagic stroke?
a) It is caused by a large-artery thrombosis.
b) One of the main presenting symptoms is numbness or weakness of the face.
c) Main presenting symptom is an "exploding headache."
d) Functional recovery usually plateaus at 6 months.
answer
Main presenting symptom is an "exploding headache."
One of hemorrhagic stroke's main presenting symptom is an "exploding headache." In ischemic stroke, functional recovery usually plateaus at 6 months; it may be caused by a large artery thrombosis and may have a presenting symptoms of numbness or weakness of the face
question
A 73-year-old client is visiting the neurologist. The client reports light-headedness, speech disturbance, and left-sided weakness that have lasted for several hours. In the examination, an abnormal sound is auscultated in an artery leading to the brain. What is the term for the auscultated discovery?
a) Atherosclerotic plaque
b) TIA
c) Diplopia
d) Bruit
answer
Bruit
A neurologic examination during an attack reveals neurologic deficits. Auscultation of the artery may reveal a bruit (abnormal sound caused by blood flowing over a rough surface within one or both carotid arteries). The term for the auscultated discovery is bruit.
question
Which of the following statements reflect nursing management of the patient with expressive aphasia?
a) Frequently reorient the patient to time, place, and situation
b) Speak clearly to the patient in simple sentences, use gestures or pictures when able
c) Speak slowly and clearly to assist the patient in forming the sounds
d) Encourage the patient to repeat sounds of the alphabet
answer
Encourage the patient to repeat sounds of the alphabet
Nursing management of the patient with expressive aphasia includes encouraging the patient to repeat sounds of the alphabet. Nursing management of the patient with global aphasia includes speaking clearly to the patient in simple sentences and using gestures or pictures when able. Nursing management of the patient with receptive aphasia includes speaking slowing and clearly to assist the patient in forming the sounds. Nursing management of the patient with cognitive deficits, such as memory loss, includes frequently reorienting the patient to time, place, and situation. (less)
question
Which of the following is the initial diagnostic test for a stroke?
a) Noncontrast CT scan
b) Transcranial Doppler studies
c) ECG
d) Carotid Doppler
answer
Noncontrast CT scan
The initial diagnostic test for a stroke is a nonconstrast CT scan performed emergently to determine if the event is ischemic or hemorrhagic. Further diagnostics include a carotid Doppler, ECG, and a transcranial Doppler. (less)
question
A patient has been diagnosed as having global aphasia. The nurse recognizes that the patient will be unable to do which of the following actions?
a) Form words that are understandable
b) Speak at all
c) Form words that are understandable or comprehend the spoken word
d) Comprehend the spoken word
answer
Form words that are understandable or comprehend the spoken word
Global aphasia is a combination of expressive and receptive aphasia and presents tremendous challenge to the nurse to effectively communicate with the patient. In receptive aphasia, the patient is unable to form words that are understandable. In expressive aphasia, the patient is unable to form words that are understandable. The patient who is unable to speak at all is referred to as mute.
question
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) 5:30 p.m.
b) 3:00 p.m.
c) 4:00 p.m.
d) 2:30 p.m.
answer
4:00 p.m.
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.
question
The nurse is providing diet-related advice to a male patient following a cerebrovascular accident (CVA). The patient wants to minimize the volume of food and yet meet all nutritional elements. Which of the following suggestions should the nurse give to the patient about controlling the volume of food intake?
a) Provide a high-fat diet.
b) Include dry or crisp foods and chewy meats.
c) Always serve hot or tepid foods.
d) Provide thickened commercial beverages and fortified cooked cereals.
answer
Provide thickened commercial beverages and fortified cooked cereals.
Patients with CVA or other cerebrovascular disorders should lose weight and therefore should minimize their volume of food consumption. To ensure this, the nurse may provide thickened commercial beverages, fortified cooked cereals, or scrambled eggs. Patients should avoid eating high-fat foods, and serving foods hot or tepid will not minimize the volume consumed by the patient. Foods such as peanut butter, bread, tart foods, dry or crisp foods, and chewy meats should also be avoided because they cause choking.
question
A client is receiving an I.V. infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant?
a) Elevated blood pressure
b) Decreased level of consciousness (LOC)
c) Increased urine output
d) Decreased heart rate
answer
Increased urine output
The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output. A decreased LOC and elevated blood pressure may indicate lack of therapeutic effectiveness. A decreased heart rate doesn't indicate that mannitol is effective.
question
Which of the following is a contraindication for the administration of tissue plasminogen activator (t-PA)?
a) Systolic blood pressure less than or equal to 185 mm Hg
b) Ischemic stroke
c) Intracranial hemorrhage
d) Age 18 years of age or older
answer
Intracranial hemorrhage
Intracranial hemorrhage, neoplasm, or aneurysm is a contraindication to t-PA. Clinical diagnosis of ischemic stroke, age 18 years of age or older, and a systolic BP less than or equal to 185 mm Hg are eligibility criteria. (less)
Haven't found what you need?
Search for quizzes and test answers now
Quizzes.studymoose.com uses cookies. By continuing you agree to our cookie policy
