NUR 2520 - Unit II - Stroke/Seizures Questions With
Complete Solutions
A 50-year-old man complains of recurring headaches. He
describes these as sharp, stabbing, and located around his left
eye. He also reports that his left eye seems to swell and get teary
when these headaches occur. Based on this history, you suspect
that he has
a. cluster headaches
b. tension headaches
c. migraine headaches
d. medication overuse headaches Correct Answers a. cluster
headaches
Rationale: Cluster headaches involve repeated headaches that
can occur for weeks to months, followed by periods of
remission. The pain of cluster headache is sharp and stabbing;
the intense pain lasts a few minutes to 3 hours. Cluster
headaches can occur every other day and as often as eight times
a day. The clusters occur with regularity, usually occurring at
the same time each day and during the same seasons of the year.
Typically, a cluster lasts 2 weeks to 3 months, and the patient
then goes into remission for months to years. The pain usually is
located around the eye and radiates to the temple, forehead,
cheek, nose, or gums. Other manifestations may include
swelling around the eye, lacrimation (tearing), facial flushing or
pallor, nasal congestion, and constriction of the pupil. During
the headache, the patient is often agitated and restless, unable to
sit still or relax.
,A 74-year-old man who has right-sided extremity paralysis
related to a thrombotic stroke develops constipation. Which
action should the nurse take first?
a. Assist the patient to the bathroom every 2 hours.
b. Provide incontinence briefs to wear during the day.
c. Administer a bisacodyl (Dulcolax) rectal suppository every
day.
d. Arrange for several servings per day of cooked fruits and
vegetables. Correct Answers d. Arrange for several servings
per day of cooked fruits and vegetables.
Patients after a stroke frequently have constipation. Dietary
management includes the following: fluid intake of 2500 to
3000 mL daily, prune juice (120 mL) or stewed prunes daily,
cooked fruit three times daily, cooked vegetables three times
daily, and whole-grain cereal or bread three to five times daily.
Patients with urinary incontinence should be assisted to the
bathroom every 2 hours when appropriate. Suppositories may be
ordered for short-term management if the patient does not
respond to increased fluid and fiber. Incontinence briefs are
indicated as a short-term intervention for urinary incontinence.
A female patient complains of a throbbing headache. When her
history is obtained, the nurse discovers that the patient has had
this type of headache before and experienced photophobia
before the headache occurred. The nurse should know that what
is probably the cause of this patient's headache?
a. Polycythemia vera
b. A cluster headache
, c. A migraine headache
d. A hemorrhagic stroke Correct Answers c. A migraine
headache
Although a headache may occur with any of these options, a
migraine headache is the only one that has a throbbing headache
with an aura (the photophobia). Headache from polycythemia
vera is from erythrocytosis. The cluster headache pain is sharp
and stabbing, and the headache with a hemorrhagic stroke has a
sudden onset and is not recurrent.
A female patient has left-sided hemiplegia following an
ischemic stroke that she experienced 4 days earlier. How should
the nurse best promote the health of the patient's integumentary
system?
a. Position the patient on her weak side the majority of the time.
b. Alternate the patient's positioning between supine and side-
lying.
c. Avoid the use of pillows in order to promote independence in
positioning.
d. Establish a schedule for the massage of areas where skin
breakdown emerges. Correct Answers b. Alternate the patient's
positioning between supine and side-lying.
A position change schedule should be established for stroke
patients. An example is side-back-side, with a maximum
duration of 2 hours for any position. The patient should be
positioned on the weak or paralyzed side for only 30 minutes.
Pillows may be used to facilitate positioning. Areas of skin
breakdown should never be massaged.
Complete Solutions
A 50-year-old man complains of recurring headaches. He
describes these as sharp, stabbing, and located around his left
eye. He also reports that his left eye seems to swell and get teary
when these headaches occur. Based on this history, you suspect
that he has
a. cluster headaches
b. tension headaches
c. migraine headaches
d. medication overuse headaches Correct Answers a. cluster
headaches
Rationale: Cluster headaches involve repeated headaches that
can occur for weeks to months, followed by periods of
remission. The pain of cluster headache is sharp and stabbing;
the intense pain lasts a few minutes to 3 hours. Cluster
headaches can occur every other day and as often as eight times
a day. The clusters occur with regularity, usually occurring at
the same time each day and during the same seasons of the year.
Typically, a cluster lasts 2 weeks to 3 months, and the patient
then goes into remission for months to years. The pain usually is
located around the eye and radiates to the temple, forehead,
cheek, nose, or gums. Other manifestations may include
swelling around the eye, lacrimation (tearing), facial flushing or
pallor, nasal congestion, and constriction of the pupil. During
the headache, the patient is often agitated and restless, unable to
sit still or relax.
,A 74-year-old man who has right-sided extremity paralysis
related to a thrombotic stroke develops constipation. Which
action should the nurse take first?
a. Assist the patient to the bathroom every 2 hours.
b. Provide incontinence briefs to wear during the day.
c. Administer a bisacodyl (Dulcolax) rectal suppository every
day.
d. Arrange for several servings per day of cooked fruits and
vegetables. Correct Answers d. Arrange for several servings
per day of cooked fruits and vegetables.
Patients after a stroke frequently have constipation. Dietary
management includes the following: fluid intake of 2500 to
3000 mL daily, prune juice (120 mL) or stewed prunes daily,
cooked fruit three times daily, cooked vegetables three times
daily, and whole-grain cereal or bread three to five times daily.
Patients with urinary incontinence should be assisted to the
bathroom every 2 hours when appropriate. Suppositories may be
ordered for short-term management if the patient does not
respond to increased fluid and fiber. Incontinence briefs are
indicated as a short-term intervention for urinary incontinence.
A female patient complains of a throbbing headache. When her
history is obtained, the nurse discovers that the patient has had
this type of headache before and experienced photophobia
before the headache occurred. The nurse should know that what
is probably the cause of this patient's headache?
a. Polycythemia vera
b. A cluster headache
, c. A migraine headache
d. A hemorrhagic stroke Correct Answers c. A migraine
headache
Although a headache may occur with any of these options, a
migraine headache is the only one that has a throbbing headache
with an aura (the photophobia). Headache from polycythemia
vera is from erythrocytosis. The cluster headache pain is sharp
and stabbing, and the headache with a hemorrhagic stroke has a
sudden onset and is not recurrent.
A female patient has left-sided hemiplegia following an
ischemic stroke that she experienced 4 days earlier. How should
the nurse best promote the health of the patient's integumentary
system?
a. Position the patient on her weak side the majority of the time.
b. Alternate the patient's positioning between supine and side-
lying.
c. Avoid the use of pillows in order to promote independence in
positioning.
d. Establish a schedule for the massage of areas where skin
breakdown emerges. Correct Answers b. Alternate the patient's
positioning between supine and side-lying.
A position change schedule should be established for stroke
patients. An example is side-back-side, with a maximum
duration of 2 hours for any position. The patient should be
positioned on the weak or paralyzed side for only 30 minutes.
Pillows may be used to facilitate positioning. Areas of skin
breakdown should never be massaged.
