S4 UNIT 3 QUESTIONS 1: WITH CORRECT
ANSWERS <VERIFIED ANSWERS> NEWEST
EXAM WITH COMPLETE SOLUTIONS
During change of shift report, a nurse is told that a patient has an occluded left
posterior cerebral artery. What finding should the nurse anticipate?
Dysphasia
Confusion
Visual deficits
Poor judgment - ANSWER - Visual deficits
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.
What will the nurse tell the patient who has cerebral atherosclerosis about taking
clopidogrel (Plavix)?
Monitor and record the blood pressure daily.
Call the health care provider if stools are tarry.
Clopidogrel will dissolve clots in the cerebral arteries.
Clopidogrel will reduce cerebral artery plaque formation. - ANSWER - Call the
health care provider if stools are tarry.
Clopidogrel 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.
A patient with carotid atherosclerosis asks the nurse to describe a carotid
endarterectomy. Which response by the nurse is accurate?
"The diseased portion of the artery is replaced with a synthetic graft."
"The obstructing plaque is surgically removed from inside an artery in the neck."
"A wire is threaded through an artery in the leg to the clots in the carotid artery,
and clots are removed."
"A catheter with a deflated balloon is positioned at the narrow area, and the
balloon flattens the plaque." - ANSWER - "The obstructing plaque is surgically
removed from inside an artery in the neck."
In a carotid endarterectomy, the carotid artery is incised, and the plaque is
removed. The response beginning, "The diseased portion of the artery 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.
A patient admitted with possible stroke has been aphasic for 3 hours and has a
current blood pressure (BP) of 174/94 mm Hg. Which order by the health care
provider should the nurse question?
Keep head of bed elevated at least 30 degrees.
Infuse normal saline intravenously at 75 mL/hr.
Start a labetalol drip to keep BP less than 140/90 mm Hg.
, Begin tissue plasminogen activator (tape) intravenously per protocol. - ANSWER -
Start a labetalol drip to keep BP less than 140/90 mm Hg.
Because elevated BP may be a protective response to maintain cerebral
perfusion, antihypertensive therapy is recommended only if mean arterial
pressure (MAP) is greater than130 mm Hg or systolic pressure is greater than 220
mm Hg. Fluid intake should be 1500 to 2000 mL/day 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. tape may be administered if the
patient meets the other criteria for tape use.
A patient arrives in the emergency department with hemiparesis and dysarthria
that started 2 hours previously. Health records show a history of several transient
ischemic attacks (TIAs). What should the nurse anticipate for this patient?
Surgical endarterectomy
Transluminal angioplasty
Intravenous heparin drip administration
Tissue plasminogen activator (tape) infusion - ANSWER - Tissue plasminogen
activator (tape) infusion
The patient's 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 tape
(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.
A female patient who had a stroke 24 hours ago has expressive aphasia. What is
an appropriate nursing intervention to help the patient communicate?
Ask questions that the patient can answer with "yes" or "no."
ANSWERS <VERIFIED ANSWERS> NEWEST
EXAM WITH COMPLETE SOLUTIONS
During change of shift report, a nurse is told that a patient has an occluded left
posterior cerebral artery. What finding should the nurse anticipate?
Dysphasia
Confusion
Visual deficits
Poor judgment - ANSWER - Visual deficits
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.
What will the nurse tell the patient who has cerebral atherosclerosis about taking
clopidogrel (Plavix)?
Monitor and record the blood pressure daily.
Call the health care provider if stools are tarry.
Clopidogrel will dissolve clots in the cerebral arteries.
Clopidogrel will reduce cerebral artery plaque formation. - ANSWER - Call the
health care provider if stools are tarry.
Clopidogrel 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.
A patient with carotid atherosclerosis asks the nurse to describe a carotid
endarterectomy. Which response by the nurse is accurate?
"The diseased portion of the artery is replaced with a synthetic graft."
"The obstructing plaque is surgically removed from inside an artery in the neck."
"A wire is threaded through an artery in the leg to the clots in the carotid artery,
and clots are removed."
"A catheter with a deflated balloon is positioned at the narrow area, and the
balloon flattens the plaque." - ANSWER - "The obstructing plaque is surgically
removed from inside an artery in the neck."
In a carotid endarterectomy, the carotid artery is incised, and the plaque is
removed. The response beginning, "The diseased portion of the artery 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.
A patient admitted with possible stroke has been aphasic for 3 hours and has a
current blood pressure (BP) of 174/94 mm Hg. Which order by the health care
provider should the nurse question?
Keep head of bed elevated at least 30 degrees.
Infuse normal saline intravenously at 75 mL/hr.
Start a labetalol drip to keep BP less than 140/90 mm Hg.
, Begin tissue plasminogen activator (tape) intravenously per protocol. - ANSWER -
Start a labetalol drip to keep BP less than 140/90 mm Hg.
Because elevated BP may be a protective response to maintain cerebral
perfusion, antihypertensive therapy is recommended only if mean arterial
pressure (MAP) is greater than130 mm Hg or systolic pressure is greater than 220
mm Hg. Fluid intake should be 1500 to 2000 mL/day 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. tape may be administered if the
patient meets the other criteria for tape use.
A patient arrives in the emergency department with hemiparesis and dysarthria
that started 2 hours previously. Health records show a history of several transient
ischemic attacks (TIAs). What should the nurse anticipate for this patient?
Surgical endarterectomy
Transluminal angioplasty
Intravenous heparin drip administration
Tissue plasminogen activator (tape) infusion - ANSWER - Tissue plasminogen
activator (tape) infusion
The patient's 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 tape
(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.
A female patient who had a stroke 24 hours ago has expressive aphasia. What is
an appropriate nursing intervention to help the patient communicate?
Ask questions that the patient can answer with "yes" or "no."
