EXAM 5 WITH QUESTIONS AND CORRECT
ANSWERS |WITH COMPLETE SOLUTION
Which modifiable risk factors for stroke would be most important for the nurse to
include when planning a community education program?
A. Hypertension
B. Hyperlipidemia
C. Alcohol consumption
D. Oral contraceptive use - ANSWER - A. Hypertension
Hypertension is the single most important modifiable risk factor, but it is still
often undetected and inadequately treated. The public is often more aware of
hyperlipidemia and oral contraceptive use as risk factors for stroke. Alcohol is also
a modifiable risk factor.
The nurse would expect to find what clinical manifestation in a patient admitted
with a left-sided stroke?
A. Impulsivity
B. Impaired speech
C. Left-side neglect
D. Short attention span - ANSWER - B. Impaired speech
Clinical manifestations of left-sided brain damage include right hemiplegia,
impaired speech/language, impaired right/left discrimination, and slow and
,cautious performance. Impulsivity, left-sided neglect, and short attention span
are all manifestations of right-sided brain damage.
The nurse is discharging a patient admitted with a transient ischemic attack (TIA).
For which medications might the nurse expect to provide discharge instructions
(select all that apply)?
A. Clopidogrel (Plavix)
B. Enoxaparin (Love NOx)
C. Dipyridamole (Presenting)
D. Enteric-coated aspirin (Escorting)
E. Tissue plasminogen activator (tape) - ANSWER - A. Clopidogrel (Plavix)
C. Dipyridamole (Presenting)
D. Enteric-coated aspirin (Escorting)
Aspirin is the most frequently used antiplatelet agent. Other drugs to prevent clot
formation include clopidogrel (Plavix), dipyridamole (Presenting), ticlopidine (Tic
lid), combined dipyridamole and aspirin (Aggrenox), and anticoagulant drugs, such
as oral warfarin (Coumadin). Tissue plasminogen activator is a fibrinolytic
medication used to treat ischemic stroke not prevent TIAs or strokes.
Which intervention is most appropriate when communicating with a patient
suffering from aphasia following a stroke?
A. Present several thoughts at once so that the patient can connect the ideas.
B. Ask open-ended questions to provide the patient the opportunity to speak.
,C. Finish the patient's sentences to minimize frustration associated with slow
speech.
D. Use simple, short sentences accompanied by visual cues to enhance
comprehension. - ANSWER - D. Use simple, short sentences accompanied by
visual cues to enhance comprehension.
When communicating with a patient with aphasia, the nurse should present one
thought or idea at a time. Ask questions that can be answered with a "yes," "no,"
or simple word. Use visual cues and allow time for the individual to comprehend
and respond to conversation.
Computed tomography (CT) of a 68-year-old male patient's head reveals that he
has experienced a hemorrhagic stroke. What is the priority nursing intervention in
the emergency department?
A. Maintenance of patient's airway.
B. Positioning to promote cerebral perfusion.
C. Control of fluid and electrolyte imbalances.
D. Administration of tissue plasminogen activator (tape) - ANSWER - A.
Maintenance of patient's airway.
Maintenance of a patent airway is the priority in the acute care of a patient with a
hemorrhagic stroke. It supersedes the importance of fluid and electrolyte
imbalance and positioning. tape is contraindicated in hemorrhagic stroke.
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 message of areas where skin breakdown emerges.
- ANSWER - 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.
Which sensory-perceptual deficit is associated with left-sided stroke (right
hemiplegia)?
A. Overestimation of physical abilities.
B. Difficulty judging position and distance.
C. Slow and possibly fearful performance of tasks.
D. Impulsivity and impatience at performing tasks. - ANSWER - C. Slow and
possibly fearful performance of tasks.
Patients with a left-sided stroke (right hemiplegia) commonly are slower in
organization and performance of tasks and may have a fearful, anxious response
to a stroke. Overconfidence, spatial disorientation, and impulsivity are more
commonly associated with a right-sided stroke.
ANSWERS |WITH COMPLETE SOLUTION
Which modifiable risk factors for stroke would be most important for the nurse to
include when planning a community education program?
A. Hypertension
B. Hyperlipidemia
C. Alcohol consumption
D. Oral contraceptive use - ANSWER - A. Hypertension
Hypertension is the single most important modifiable risk factor, but it is still
often undetected and inadequately treated. The public is often more aware of
hyperlipidemia and oral contraceptive use as risk factors for stroke. Alcohol is also
a modifiable risk factor.
The nurse would expect to find what clinical manifestation in a patient admitted
with a left-sided stroke?
A. Impulsivity
B. Impaired speech
C. Left-side neglect
D. Short attention span - ANSWER - B. Impaired speech
Clinical manifestations of left-sided brain damage include right hemiplegia,
impaired speech/language, impaired right/left discrimination, and slow and
,cautious performance. Impulsivity, left-sided neglect, and short attention span
are all manifestations of right-sided brain damage.
The nurse is discharging a patient admitted with a transient ischemic attack (TIA).
For which medications might the nurse expect to provide discharge instructions
(select all that apply)?
A. Clopidogrel (Plavix)
B. Enoxaparin (Love NOx)
C. Dipyridamole (Presenting)
D. Enteric-coated aspirin (Escorting)
E. Tissue plasminogen activator (tape) - ANSWER - A. Clopidogrel (Plavix)
C. Dipyridamole (Presenting)
D. Enteric-coated aspirin (Escorting)
Aspirin is the most frequently used antiplatelet agent. Other drugs to prevent clot
formation include clopidogrel (Plavix), dipyridamole (Presenting), ticlopidine (Tic
lid), combined dipyridamole and aspirin (Aggrenox), and anticoagulant drugs, such
as oral warfarin (Coumadin). Tissue plasminogen activator is a fibrinolytic
medication used to treat ischemic stroke not prevent TIAs or strokes.
Which intervention is most appropriate when communicating with a patient
suffering from aphasia following a stroke?
A. Present several thoughts at once so that the patient can connect the ideas.
B. Ask open-ended questions to provide the patient the opportunity to speak.
,C. Finish the patient's sentences to minimize frustration associated with slow
speech.
D. Use simple, short sentences accompanied by visual cues to enhance
comprehension. - ANSWER - D. Use simple, short sentences accompanied by
visual cues to enhance comprehension.
When communicating with a patient with aphasia, the nurse should present one
thought or idea at a time. Ask questions that can be answered with a "yes," "no,"
or simple word. Use visual cues and allow time for the individual to comprehend
and respond to conversation.
Computed tomography (CT) of a 68-year-old male patient's head reveals that he
has experienced a hemorrhagic stroke. What is the priority nursing intervention in
the emergency department?
A. Maintenance of patient's airway.
B. Positioning to promote cerebral perfusion.
C. Control of fluid and electrolyte imbalances.
D. Administration of tissue plasminogen activator (tape) - ANSWER - A.
Maintenance of patient's airway.
Maintenance of a patent airway is the priority in the acute care of a patient with a
hemorrhagic stroke. It supersedes the importance of fluid and electrolyte
imbalance and positioning. tape is contraindicated in hemorrhagic stroke.
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 message of areas where skin breakdown emerges.
- ANSWER - 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.
Which sensory-perceptual deficit is associated with left-sided stroke (right
hemiplegia)?
A. Overestimation of physical abilities.
B. Difficulty judging position and distance.
C. Slow and possibly fearful performance of tasks.
D. Impulsivity and impatience at performing tasks. - ANSWER - C. Slow and
possibly fearful performance of tasks.
Patients with a left-sided stroke (right hemiplegia) commonly are slower in
organization and performance of tasks and may have a fearful, anxious response
to a stroke. Overconfidence, spatial disorientation, and impulsivity are more
commonly associated with a right-sided stroke.
