CHAPTER 58: NURSING MANAGEMENT:
STROKE, MED SURG CHAPTER 66, MED
SURG CHAPTER 67, CHAPTER 46:
CEREBRAL DYSFUNCTION
After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria
with no residual effects, the nurse anticipates teaching the patient about
a.
cerebral aneurysm clipping.
b.
heparin intravenous infusion.
c.
oral low-dose aspirin therapy.
d.
tissue plasminogen activator (tPA). - ANSWER - ANS: C
The patient's symptoms are consistent with transient ischemic attack (TIA), and
drugs that inhibit platelet aggregation are prescribed after a TIA to prevent
stroke. Continuous heparin infusion is not routinely used after TIA or with acute
ischemic stroke. The patient's symptoms are not consistent with a cerebral
aneurysm. tPA is used only for acute ischemic stroke, not for TIA.
DIF: Cognitive Level: Apply (application) REF: 1391 | 1396
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
,A patient has had an ischemic stroke and has been admitted to the medical unit.
What action should the nurse perform to best prevent joint deformities?
A)
Place the patient in the prone position for 30 minutes/day.
B)
Assist the patient in acutely flexing the thigh to promote movement.
C)
Place a pillow in the axilla when there is limited external rotation.
D)
Place patient's hand in pronation. - ANSWER - Ans:
C
Feedback:
A pillow in the axilla prevents adduction of the affected shoulder and keeps the
arm away from the chest. The prone position with a pillow under the pelvis, not
flat, promotes hyperextension of the hip joints, essential for normal gait. To
promote venous return and prevent edema, the upper thigh should not be flexed
acutely. The hand is placed in slight supination, not pronation, which is its most
functional position.
Which term is used to describe a childs level of consciousness when the child can
be aroused with stimulation?
a. Stupor
b. Confusion
,c. Obtundation
d. Disorientation - ANSWER - ANS: C
Obtundation describes a level of consciousness in which the child can be aroused
with stimulation. Stupor is a state in which the child remains in a deep sleep,
responsive only to vigorous and repeated stimulation.
Confusion is impaired decision making. Disorientation is confusion regarding time
and place. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1463
OBJ: Nursing Process: Assessment MSC:
A patient is being admitted to the neurologic ICU following an acute head injury
that has resulted in cerebral edema. When planning this patient's care, the nurse
would expect to administer what priority medication?
A)
Hydrochlorothiazide (HydroDIURIL)
B)
Furosemide (Lasix)
C)
Mannitol (Osmitrol)
D)
Spirolactone (Aldactone) - ANSWER - Ans:
C
Feedback:
The osmotic diuretic mannitol is given to dehydrate the brain tissue and reduce
cerebral edema. This drug acts by reducing the volume of brain and extracellular
, fluid. Spirolactone, furosemide, and hydrochlorothiazide are diuretics that are not
typically used in the treatment of increased ICP resulting from cerebral edema.
A 68-year-old patient is being admitted with a possible stroke. Which information
from the assessment indicates that the nurse should consult with the health care
provider before giving the prescribed aspirin?
a.
The patient has dysphasia.
b.
The patient has atrial fibrillation.
c.
The patient reports that symptoms began with a severe headache.
d.
The patient has a history of brief episodes of right-sided hemiplegia. - ANSWER -
ANS: C
A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is
contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack (TIA)
are not contraindications to aspirin use, so the nurse can administer the aspirin.
DIF: Cognitive Level: Apply (application) REF: 1392-1393
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
The nurse is providing care for a patient who is unconscious. What nursing
intervention takes highest priority?
A)
Maintaining accurate records of intake and output
STROKE, MED SURG CHAPTER 66, MED
SURG CHAPTER 67, CHAPTER 46:
CEREBRAL DYSFUNCTION
After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria
with no residual effects, the nurse anticipates teaching the patient about
a.
cerebral aneurysm clipping.
b.
heparin intravenous infusion.
c.
oral low-dose aspirin therapy.
d.
tissue plasminogen activator (tPA). - ANSWER - ANS: C
The patient's symptoms are consistent with transient ischemic attack (TIA), and
drugs that inhibit platelet aggregation are prescribed after a TIA to prevent
stroke. Continuous heparin infusion is not routinely used after TIA or with acute
ischemic stroke. The patient's symptoms are not consistent with a cerebral
aneurysm. tPA is used only for acute ischemic stroke, not for TIA.
DIF: Cognitive Level: Apply (application) REF: 1391 | 1396
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
,A patient has had an ischemic stroke and has been admitted to the medical unit.
What action should the nurse perform to best prevent joint deformities?
A)
Place the patient in the prone position for 30 minutes/day.
B)
Assist the patient in acutely flexing the thigh to promote movement.
C)
Place a pillow in the axilla when there is limited external rotation.
D)
Place patient's hand in pronation. - ANSWER - Ans:
C
Feedback:
A pillow in the axilla prevents adduction of the affected shoulder and keeps the
arm away from the chest. The prone position with a pillow under the pelvis, not
flat, promotes hyperextension of the hip joints, essential for normal gait. To
promote venous return and prevent edema, the upper thigh should not be flexed
acutely. The hand is placed in slight supination, not pronation, which is its most
functional position.
Which term is used to describe a childs level of consciousness when the child can
be aroused with stimulation?
a. Stupor
b. Confusion
,c. Obtundation
d. Disorientation - ANSWER - ANS: C
Obtundation describes a level of consciousness in which the child can be aroused
with stimulation. Stupor is a state in which the child remains in a deep sleep,
responsive only to vigorous and repeated stimulation.
Confusion is impaired decision making. Disorientation is confusion regarding time
and place. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1463
OBJ: Nursing Process: Assessment MSC:
A patient is being admitted to the neurologic ICU following an acute head injury
that has resulted in cerebral edema. When planning this patient's care, the nurse
would expect to administer what priority medication?
A)
Hydrochlorothiazide (HydroDIURIL)
B)
Furosemide (Lasix)
C)
Mannitol (Osmitrol)
D)
Spirolactone (Aldactone) - ANSWER - Ans:
C
Feedback:
The osmotic diuretic mannitol is given to dehydrate the brain tissue and reduce
cerebral edema. This drug acts by reducing the volume of brain and extracellular
, fluid. Spirolactone, furosemide, and hydrochlorothiazide are diuretics that are not
typically used in the treatment of increased ICP resulting from cerebral edema.
A 68-year-old patient is being admitted with a possible stroke. Which information
from the assessment indicates that the nurse should consult with the health care
provider before giving the prescribed aspirin?
a.
The patient has dysphasia.
b.
The patient has atrial fibrillation.
c.
The patient reports that symptoms began with a severe headache.
d.
The patient has a history of brief episodes of right-sided hemiplegia. - ANSWER -
ANS: C
A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is
contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack (TIA)
are not contraindications to aspirin use, so the nurse can administer the aspirin.
DIF: Cognitive Level: Apply (application) REF: 1392-1393
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
The nurse is providing care for a patient who is unconscious. What nursing
intervention takes highest priority?
A)
Maintaining accurate records of intake and output
