MED-SURG CHAPTER 60: COMPREHENSIVE QUESTIONS
AND 100% SOLVED ANSWERS
The nurse plans care for a client who has had a stroke and is experiencing residual
expressive aphasia. Which expected outcome should the nurse include in the care
plan? - ANS -3
1. The client will verbalize plans for rehabilitation.
2. The client will be satisfied with the care environment.
3. The client will demonstrate alternative communication techniques.
4. The client will demonstrate understanding that the aphasia is permanent.
A client suspected of having a subarachnoid hemorrhage is scheduled to undergo
transcranial Doppler (TCD). Which information about this procedure should the
nurse provide the client and the client's family? Select all that apply. - ANS -3,5,
1. It is an invasive procedure.
2. It provides visualization of cerebral blood vessels.
3. It is effective in detecting microemboli.
4. It requires a small dose of contrast media.
5. It measures the velocity of blood flowing through major vessels.
The nurse is screening clients to determine if administering tissue plasminogen
activator (tPA) for fibrinolytic therapy is an appropriate intervention. Which
clients may be administered tPA safely? Select all that apply. - ANS -1,2,3
, 1. A 25-year-old with history of cholecystectomy 2 years previous
2. A 70-year-old with blood sugar levels of 6.1 mmol/L
3. A 40-year-old with history of head injury 6 months ago
4. A 35-year-old with a computed tomography (CT) scan showing hemorrhagic
stroke
5. A 30-year-old with hemophilia A
In ischemic stroke, recombinant tPA is used to produce localized fibrinolysis by
binding to the fibrin thrombi. Clients are screened before tPA can be given.
Screening includes a noncontrast CT or magnetic resonance imaging to rule out
hemorrhagic stroke; blood test for glucose level and coagulation disorders; and
screening for recent history of gastrointestinal bleeding, stroke or head trauma
within past 3 months, or major surgery within 14 days. The client who underwent
major surgery 2 years ago can be given tPA, because there is no risk of bleeding.
The client with a blood sugar level of 110 mg/dL can be administered tPA safely,
because the blood sugar level is normal. The client with a history of head injury 6
months previous can also be administered tPA, because there is no risk of
bleeding. However, the client with a CT scan showing hemorrhagic stroke and the
client with hemophilia have very high risks of bleeding with the fibrinolytic action
of tPA; therefore, it should not be administered to these clients.
The nurse is formulating a discharge teaching plan for a client who had a stroke 2
weeks ago. Which instructions should the nurse include in the plan? Select all that
apply. - ANS -1,3,4
1. Follow-up for rehabilitation therapy is important.
2. Maintain strict bed rest.
3. Seek spiritual assistance.
AND 100% SOLVED ANSWERS
The nurse plans care for a client who has had a stroke and is experiencing residual
expressive aphasia. Which expected outcome should the nurse include in the care
plan? - ANS -3
1. The client will verbalize plans for rehabilitation.
2. The client will be satisfied with the care environment.
3. The client will demonstrate alternative communication techniques.
4. The client will demonstrate understanding that the aphasia is permanent.
A client suspected of having a subarachnoid hemorrhage is scheduled to undergo
transcranial Doppler (TCD). Which information about this procedure should the
nurse provide the client and the client's family? Select all that apply. - ANS -3,5,
1. It is an invasive procedure.
2. It provides visualization of cerebral blood vessels.
3. It is effective in detecting microemboli.
4. It requires a small dose of contrast media.
5. It measures the velocity of blood flowing through major vessels.
The nurse is screening clients to determine if administering tissue plasminogen
activator (tPA) for fibrinolytic therapy is an appropriate intervention. Which
clients may be administered tPA safely? Select all that apply. - ANS -1,2,3
, 1. A 25-year-old with history of cholecystectomy 2 years previous
2. A 70-year-old with blood sugar levels of 6.1 mmol/L
3. A 40-year-old with history of head injury 6 months ago
4. A 35-year-old with a computed tomography (CT) scan showing hemorrhagic
stroke
5. A 30-year-old with hemophilia A
In ischemic stroke, recombinant tPA is used to produce localized fibrinolysis by
binding to the fibrin thrombi. Clients are screened before tPA can be given.
Screening includes a noncontrast CT or magnetic resonance imaging to rule out
hemorrhagic stroke; blood test for glucose level and coagulation disorders; and
screening for recent history of gastrointestinal bleeding, stroke or head trauma
within past 3 months, or major surgery within 14 days. The client who underwent
major surgery 2 years ago can be given tPA, because there is no risk of bleeding.
The client with a blood sugar level of 110 mg/dL can be administered tPA safely,
because the blood sugar level is normal. The client with a history of head injury 6
months previous can also be administered tPA, because there is no risk of
bleeding. However, the client with a CT scan showing hemorrhagic stroke and the
client with hemophilia have very high risks of bleeding with the fibrinolytic action
of tPA; therefore, it should not be administered to these clients.
The nurse is formulating a discharge teaching plan for a client who had a stroke 2
weeks ago. Which instructions should the nurse include in the plan? Select all that
apply. - ANS -1,3,4
1. Follow-up for rehabilitation therapy is important.
2. Maintain strict bed rest.
3. Seek spiritual assistance.
