, lOMoARcPSD|25701531
Page 795
Chapter . Nursing Care of Patients With Cerebrovascular Disorders
MULTIPLE CHOICE
1. The nurse is providing care for a patient diagnosed with a stroke resulting in language
disorder. Which type of disorder does the nurse recognize if the patient raises an arm in
response to the nurse’s direction to stick out his tongue?
1. Dysarthria
2. Expressive aphasia
3. Dysphasia
4. Receptive aphasia
ANS: 4
Chapter: Chapter 49. Nursing Care of Patients With Cerebrovascular Disorders
Objective: Describe causes, risk factors, and pathophysiology of transient ischemic attack,
ischemic stroke, and hemorrhagic stroke.
Page: 1057
Heading: Language Disturbances
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity—Physiological Adaptation
Cognitive Level: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Moderate
Feedback
1 Slurred or indistinct speech (dysarthria) is caused when the stroke has caused a
motor problem.
2 Expressive aphasia is when the patient knows what he wants to say but cannot
speak or make sense.
3 Dysphasia is when the patient experiences trouble selecting the correct words,
uses incomprehensible or nonsense speech, has trouble understanding other’s
speech, and has trouble writing or reading. Even with this description, it is not
as serious as aphasia.
4 The patient has receptive aphasia, which is the inability to understand spoken
and/or written words.
PTS: 1 CON: Neurologic Regulation
2. A patient arrives at the emergency department and states, “Something is wrong. I just don’t
feel right.” Which objective data causes the nurse to suspect the patient is experiencing
some type of stroke?
1. Symptoms have been increasing in severity for several days.
2. Ataxia is present when the patient attempts to ambulate.
3. The patient was diagnosed with hypertension managed with medication.
4. The patient appears upset and cries easily throughout assessment.
ANS: 2
Chapter: Chapter 49. Nursing Care of Patients With Cerebrovascular Disorders
Page 795 of 919
, lOMoARcPSD|25701531
Page 796
Objective: Identify emergency interventions for transient ischemic attack, ischemic stroke,
and hemorrhagic stroke.
Page: 1056
Heading: Motor Disturbances
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity—Reduction of Risk Potential
Cognitive Level: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Difficult
Feedback
1 The symptoms of a stroke usually have a rapid onset. However, the information
that symptoms have been increasing in severity for several days is subjective
data.
2 Ataxia may occur with a stroke and includes poor balance or stumbling, and a
staggering gate. This data is objective and strongly related to a stroke.
3 Diagnosis of hypertension and treatment with medication is subjective data.
However, hypertension is a major contributor to stroke.
4 The patient appearing upset and crying easily is objective data; however,
neither manifestation is unique to a stroke.
PTS: 1 CON: Neurologic Regulation
3. The nurse is providing care for a patient diagnosed with an ischemic stroke on the left side
of the brain. The nurse notices that the patient does not easily locate items placed at the
bedside. In which area does the nurse place items for easy location?
1. On the left side
2. Directly in front
3. One the right side
4. As the patient wants
ANS: 3
Chapter: Chapter 49. Nursing Care of Patients With Cerebrovascular Disorders
Objective: Describe causes, risk factors, and pathophysiology of transient ischemic attack,
ischemic stroke, and hemorrhagic stroke.
Page: 1067
Heading: Visual Disturbances
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity—Physiological Adaptation
Cognitive Level: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Moderate
Feedback
1 The left side is not where the nurse places items for the patient. When a stroke
is diagnosed on the left side, the eye that is affected is on the same side as the
affected artery.
2 Placing items directly in front of the patient may not be convenient at all times.
3 The patient with a stroke on the left side will have vision in the right eye. Items
Page 796 of 919
, lOMoARcPSD|25701531
Stuvia.com - The Marketplace to Buy and Sell your Study Material
Page 797
should be place on the right side.
4 The patient may not be able to designate where items should be placed because
of the effects of the stroke. The nurse knows that the best vision is on the right
side.
PTS: 1 CON: Neurologic Regulation
4. A patient comes into the emergency department with symptoms of a stroke. Which
medication does the nurse expect to be given to the patient if diagnostic testing confirms an
ischemic stroke?
1. Heparin
2. Clopidogrel
3. Warfarin
4. Tissue-type plasminogen activator (tPA)
ANS: 4
Chapter: Chapter 49. Nursing Care of Patients With Cerebrovascular Disorders
Objective: Identify emergency interventions for transient ischemic attack, ischemic stroke,
and hemorrhagic stroke.
Page: 1060
Heading: Ischemic Stroke
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity—Pharmacological Therapies
Cognitive Level: Application (Applying)
Concept: Neurologic Regulation
Difficulty: Moderate
Feedback
1 Heparin can help prevent clots but is not effective in breaking up an existing
clot.
2 Clopidogrel can help prevent clots but is not effective in breaking up an
existing clot.
3 Warfarin can help prevent clots but is not effective in breaking up an existing
clot.
4 tPA is a thrombolytic agent that can break down the thrombus causing the
occlusion, which can potentially prevent or completely reverse the symptoms
of an ischemic stroke.
PTS: 1 CON: Neurologic Regulation
5. A patient comes into the emergency department with unilateral paralysis, aphasia, and
inability to follow directions. Which emergency management by the health care provider
(HCP) is unexpected by the nurse?
1. Maintenance of oxygen therapy to a saturation of at least 94 percent
2. Careful monitoring of changes in the patient’s level of consciousness
3. Scheduling laboratory tests, electrocardiogram (ECG), and computerized
tomography (CT) scan to be performed within 45 minutes
4. Immediate treatment for temperature greater than 99.6°F
Page 797 of 919
Page 795
Chapter . Nursing Care of Patients With Cerebrovascular Disorders
MULTIPLE CHOICE
1. The nurse is providing care for a patient diagnosed with a stroke resulting in language
disorder. Which type of disorder does the nurse recognize if the patient raises an arm in
response to the nurse’s direction to stick out his tongue?
1. Dysarthria
2. Expressive aphasia
3. Dysphasia
4. Receptive aphasia
ANS: 4
Chapter: Chapter 49. Nursing Care of Patients With Cerebrovascular Disorders
Objective: Describe causes, risk factors, and pathophysiology of transient ischemic attack,
ischemic stroke, and hemorrhagic stroke.
Page: 1057
Heading: Language Disturbances
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity—Physiological Adaptation
Cognitive Level: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Moderate
Feedback
1 Slurred or indistinct speech (dysarthria) is caused when the stroke has caused a
motor problem.
2 Expressive aphasia is when the patient knows what he wants to say but cannot
speak or make sense.
3 Dysphasia is when the patient experiences trouble selecting the correct words,
uses incomprehensible or nonsense speech, has trouble understanding other’s
speech, and has trouble writing or reading. Even with this description, it is not
as serious as aphasia.
4 The patient has receptive aphasia, which is the inability to understand spoken
and/or written words.
PTS: 1 CON: Neurologic Regulation
2. A patient arrives at the emergency department and states, “Something is wrong. I just don’t
feel right.” Which objective data causes the nurse to suspect the patient is experiencing
some type of stroke?
1. Symptoms have been increasing in severity for several days.
2. Ataxia is present when the patient attempts to ambulate.
3. The patient was diagnosed with hypertension managed with medication.
4. The patient appears upset and cries easily throughout assessment.
ANS: 2
Chapter: Chapter 49. Nursing Care of Patients With Cerebrovascular Disorders
Page 795 of 919
, lOMoARcPSD|25701531
Page 796
Objective: Identify emergency interventions for transient ischemic attack, ischemic stroke,
and hemorrhagic stroke.
Page: 1056
Heading: Motor Disturbances
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity—Reduction of Risk Potential
Cognitive Level: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Difficult
Feedback
1 The symptoms of a stroke usually have a rapid onset. However, the information
that symptoms have been increasing in severity for several days is subjective
data.
2 Ataxia may occur with a stroke and includes poor balance or stumbling, and a
staggering gate. This data is objective and strongly related to a stroke.
3 Diagnosis of hypertension and treatment with medication is subjective data.
However, hypertension is a major contributor to stroke.
4 The patient appearing upset and crying easily is objective data; however,
neither manifestation is unique to a stroke.
PTS: 1 CON: Neurologic Regulation
3. The nurse is providing care for a patient diagnosed with an ischemic stroke on the left side
of the brain. The nurse notices that the patient does not easily locate items placed at the
bedside. In which area does the nurse place items for easy location?
1. On the left side
2. Directly in front
3. One the right side
4. As the patient wants
ANS: 3
Chapter: Chapter 49. Nursing Care of Patients With Cerebrovascular Disorders
Objective: Describe causes, risk factors, and pathophysiology of transient ischemic attack,
ischemic stroke, and hemorrhagic stroke.
Page: 1067
Heading: Visual Disturbances
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity—Physiological Adaptation
Cognitive Level: Analysis (Analyzing)
Concept: Neurologic Regulation
Difficulty: Moderate
Feedback
1 The left side is not where the nurse places items for the patient. When a stroke
is diagnosed on the left side, the eye that is affected is on the same side as the
affected artery.
2 Placing items directly in front of the patient may not be convenient at all times.
3 The patient with a stroke on the left side will have vision in the right eye. Items
Page 796 of 919
, lOMoARcPSD|25701531
Stuvia.com - The Marketplace to Buy and Sell your Study Material
Page 797
should be place on the right side.
4 The patient may not be able to designate where items should be placed because
of the effects of the stroke. The nurse knows that the best vision is on the right
side.
PTS: 1 CON: Neurologic Regulation
4. A patient comes into the emergency department with symptoms of a stroke. Which
medication does the nurse expect to be given to the patient if diagnostic testing confirms an
ischemic stroke?
1. Heparin
2. Clopidogrel
3. Warfarin
4. Tissue-type plasminogen activator (tPA)
ANS: 4
Chapter: Chapter 49. Nursing Care of Patients With Cerebrovascular Disorders
Objective: Identify emergency interventions for transient ischemic attack, ischemic stroke,
and hemorrhagic stroke.
Page: 1060
Heading: Ischemic Stroke
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity—Pharmacological Therapies
Cognitive Level: Application (Applying)
Concept: Neurologic Regulation
Difficulty: Moderate
Feedback
1 Heparin can help prevent clots but is not effective in breaking up an existing
clot.
2 Clopidogrel can help prevent clots but is not effective in breaking up an
existing clot.
3 Warfarin can help prevent clots but is not effective in breaking up an existing
clot.
4 tPA is a thrombolytic agent that can break down the thrombus causing the
occlusion, which can potentially prevent or completely reverse the symptoms
of an ischemic stroke.
PTS: 1 CON: Neurologic Regulation
5. A patient comes into the emergency department with unilateral paralysis, aphasia, and
inability to follow directions. Which emergency management by the health care provider
(HCP) is unexpected by the nurse?
1. Maintenance of oxygen therapy to a saturation of at least 94 percent
2. Careful monitoring of changes in the patient’s level of consciousness
3. Scheduling laboratory tests, electrocardiogram (ECG), and computerized
tomography (CT) scan to be performed within 45 minutes
4. Immediate treatment for temperature greater than 99.6°F
Page 797 of 919
