05 2900 STROKE & ICP WITH APPROVED QUESTIONS
AND ANSWERS |100% CORRECT
A client who has had a stroke stares at a nurse but does not attempt to verbally
respond to the nurse's questions. The client follows instructions without any
problems. The nurse understands that the client is displaying symptoms
consistent with:
A. receptive aphasia
B. global aphasia
C. expressive aphasia
D. both receptive and expressive aphasia - ANSWER - Correct:
C. expressive aphasia
A client is admitted to the intensive care unit with a severe stroke. The client is
receiving a continuous IV infusion titrated according to the blood glucose results
to control hyperglycemia. The client's spouse asks the nurse why the client is
receiving insulin when the client is not diabetic. Which explanations to the client's
spouse should the nurse include? SELECT ALL THAT APPLY.
A. "The body reacts to stress by producing various hormones, which result in
elevated glucose levels."
B. "The body has less effective utilization of glucose during serious illness."
C. "Insulin lessens the likelihood of brain tissue becoming swollen."
,D. "Use of insulin will decrease the likelihood of the patient becoming diabetic in
the future."
E. "A side effect of the medications administered is the development of T1DM." -
ANSWER - Correct:
A. "The body reacts to stress by producing various hormones, which result in
elevated glucose levels."
B. "The body has less effective utilization of glucose during serious illness."
C. "Insulin lessens the likelihood of brain tissue becoming swollen."
A client with a deteriorating mental status after suffering a stroke has a rectal
temp of 102.3. For which reason should a nurse initiate interventions to bring the
temperature to a normal level?
A. A normal temperature will strengthen the client's immune system against
infection.
B. Hyperthermia lowers the incidence of mortality
C. A normal temperature will decrease the score on the Glasgow coma scale
D. Hyperthermia increases the likelihood of a larger area of brain infarct. -
ANSWER - D. Hyperthermia increases the likelihood of a larger area of brain
infarct.
,A client is diagnosed with a stroke that affects the right hemisphere of the brain.
A nurse, receiving report prior to care of this client, should expect the client to
have which symptom?
A. Right hemiparesis
B. Expressive aphasia
C. Poor impulse control
D. Marked anxiety when learning new tasks - ANSWER - C. Poor impulse control
A client seeks medical attention at an ER after experiencing right-sided weakness
and slurred speech. The client receives a diagnosis of ischemic stroke and is
evaluated for treatment with thrombolytic therapy. A definite contraindication
for thrombolytic therapy is:
A. a normal CT scan of the brain
B. a serious head injury 4 weeks earlier
C. a hx of DM
D. onset of neurological deficits 2 hours earlier - ANSWER - B. a serious head
injury 4 weeks earlier
Why? Contraindications to thrombolytic therapy for a client with ischemic stroke
include a serious head injury within the previous 3 months, This would put the
patient at risk of developing serious bleeding problems (specifically hemorrhage).
A negative CT scan and onset of neurological deficits within 3 hours are
indications of administering thrombolytic therapy. History of DM is not a
contraindication.
, A client is admitted to an intensive care unit because of a leaky cerebral
aneurysm. A family member asks a nurse why the client is awakened and
questioned about his orientation so frequently when he needs to rest. The nurse
answers the family member based on the knowledge that the earliest sign of ICP
is:
A. pupillary changes
B. drop in BP
C. altered sensation
D. changes in LOC - ANSWER - D. changes in LOC
A nurse is orienting a new nurse to a unit. The experienced nurse evaluates that
the new nurse understands information r/t a stroke resulting from a subarachnoid
hemorrhage when which points are addressed by the new nurse? SELECT ALL
THAT APPLY.
A. Subarachnoid hemorrhage is often associated with a rupture of a cerebral
aneurysm.
B. Subarachnoid hemorrhage usually occurs while the client is sleeping and is
noticed when the client awakens.
C. Subarachnoid hemorrhage is accompanied by complaints of an extremely
severe headache.
D. Subarachnoid hemorrhage may be treated with thrombolytic therapy if no
contraindications exist.
AND ANSWERS |100% CORRECT
A client who has had a stroke stares at a nurse but does not attempt to verbally
respond to the nurse's questions. The client follows instructions without any
problems. The nurse understands that the client is displaying symptoms
consistent with:
A. receptive aphasia
B. global aphasia
C. expressive aphasia
D. both receptive and expressive aphasia - ANSWER - Correct:
C. expressive aphasia
A client is admitted to the intensive care unit with a severe stroke. The client is
receiving a continuous IV infusion titrated according to the blood glucose results
to control hyperglycemia. The client's spouse asks the nurse why the client is
receiving insulin when the client is not diabetic. Which explanations to the client's
spouse should the nurse include? SELECT ALL THAT APPLY.
A. "The body reacts to stress by producing various hormones, which result in
elevated glucose levels."
B. "The body has less effective utilization of glucose during serious illness."
C. "Insulin lessens the likelihood of brain tissue becoming swollen."
,D. "Use of insulin will decrease the likelihood of the patient becoming diabetic in
the future."
E. "A side effect of the medications administered is the development of T1DM." -
ANSWER - Correct:
A. "The body reacts to stress by producing various hormones, which result in
elevated glucose levels."
B. "The body has less effective utilization of glucose during serious illness."
C. "Insulin lessens the likelihood of brain tissue becoming swollen."
A client with a deteriorating mental status after suffering a stroke has a rectal
temp of 102.3. For which reason should a nurse initiate interventions to bring the
temperature to a normal level?
A. A normal temperature will strengthen the client's immune system against
infection.
B. Hyperthermia lowers the incidence of mortality
C. A normal temperature will decrease the score on the Glasgow coma scale
D. Hyperthermia increases the likelihood of a larger area of brain infarct. -
ANSWER - D. Hyperthermia increases the likelihood of a larger area of brain
infarct.
,A client is diagnosed with a stroke that affects the right hemisphere of the brain.
A nurse, receiving report prior to care of this client, should expect the client to
have which symptom?
A. Right hemiparesis
B. Expressive aphasia
C. Poor impulse control
D. Marked anxiety when learning new tasks - ANSWER - C. Poor impulse control
A client seeks medical attention at an ER after experiencing right-sided weakness
and slurred speech. The client receives a diagnosis of ischemic stroke and is
evaluated for treatment with thrombolytic therapy. A definite contraindication
for thrombolytic therapy is:
A. a normal CT scan of the brain
B. a serious head injury 4 weeks earlier
C. a hx of DM
D. onset of neurological deficits 2 hours earlier - ANSWER - B. a serious head
injury 4 weeks earlier
Why? Contraindications to thrombolytic therapy for a client with ischemic stroke
include a serious head injury within the previous 3 months, This would put the
patient at risk of developing serious bleeding problems (specifically hemorrhage).
A negative CT scan and onset of neurological deficits within 3 hours are
indications of administering thrombolytic therapy. History of DM is not a
contraindication.
, A client is admitted to an intensive care unit because of a leaky cerebral
aneurysm. A family member asks a nurse why the client is awakened and
questioned about his orientation so frequently when he needs to rest. The nurse
answers the family member based on the knowledge that the earliest sign of ICP
is:
A. pupillary changes
B. drop in BP
C. altered sensation
D. changes in LOC - ANSWER - D. changes in LOC
A nurse is orienting a new nurse to a unit. The experienced nurse evaluates that
the new nurse understands information r/t a stroke resulting from a subarachnoid
hemorrhage when which points are addressed by the new nurse? SELECT ALL
THAT APPLY.
A. Subarachnoid hemorrhage is often associated with a rupture of a cerebral
aneurysm.
B. Subarachnoid hemorrhage usually occurs while the client is sleeping and is
noticed when the client awakens.
C. Subarachnoid hemorrhage is accompanied by complaints of an extremely
severe headache.
D. Subarachnoid hemorrhage may be treated with thrombolytic therapy if no
contraindications exist.
