Chapter 60: Nursing Management:
Stroke Lewis et al.: Medical-Surgical
Nursing in Canada, 3rd Edition
1. The nurse obtains all the following records approximately a sixty five-12 months-vintage
patient within the medical institution. When growing a plan to lower stroke hazard, which hazard
factor is most crucial for the nurse to cope with?
A. The affected person smokes a percent of cigarettes each day.
B. The affected person's blood pressure is chronically among a hundred and fifty/80 and one
hundred seventy/ninety mm Hg.
C. The patient works at a table and relaxes with the aid of watching tv.
D. The patient is 11.Three kg above the perfect weight. - ANS-ANS: B
Hypertension is the maximum important modifiable risk issue.
PTS: 1 DIF: Cognitive Level: Application REF: page 1674
OBJ: 1 TOP: Nursing Process: Planning MSC: CRNE: HW-2
10. A 68-yr-vintage guy has had numerous TIAs with transient hemiparesis and dysarthria which
have lasted as much as an hour. The nurse encourages the affected person to seek immediate
clinical help for any symptoms that remaining longer than an hour, explaining that permanent
incapacity from a stroke may be reduced if remedy is initiated within 3 hours with using which of
the subsequent treatments?
A. IV heparin
b. Transluminal angioplasty
c. A surgical endarterectomy
d. TPA - ANS-ANS: D
The affected person's history and scientific manifestations suggest an acute ischemic stroke,
and a patient who's visible within three hours of stroke onset is in all likelihood to get hold of tPA
(after screening with a CT experiment).
PTS: 1 DIF: Cognitive Level: Comprehension REF: page 1683
OBJ: 7 TOP: Nursing Process: Implementation MSC: CRNE: CH-sixty one
eleven. The nurse identifies the nursing analysis of impaired verbal verbal exchange for a
affected person with expressive aphasia. What is the best nursing intervention to help the
patient talk?
A. Ask easy questions that can be responded with "yes" or "no."
b. Develop a listing of simple phrases that she can study and coaching reciting.
C. Have her training facial and tongue physical games to improve motor manipulate vital for
speech.
, D. Prevent embarrassing her through changing the difficulty if she does no longer reply in a well
timed way. - ANS-ANS: A
Communication can be facilitated and much less irritating to the patient whilst questions that
require a "sure" or "no" reaction are used.
PTS: 1 DIF: Cognitive Level: Application REF: web page 1692, Table 60-9
OBJ: 7 TOP: Nursing Process: Implementation MSC: CRNE: NCP-2
12. Twenty-four hours after admission, a affected person with a stroke has revolutionary
improvement of neurological deficits with increasing weak spot and reduced level of attention.
What is the primary goal of nursing control of the affected person at the moment?
A. Protecting the pores and skin from breakdown
b. Monitoring for adjustments in neurological repute
c. Maintaining the affected person's breathing characteristic
d. Preventing joint contractures and muscle atrophy - ANS-ANS: C
Protection of the airway is the priority of nursing take care of a affected person having an acute
stroke.
PTS: 1 DIF: Cognitive Level: Comprehension REF: web page 1687
OBJ: 7 TOP: Nursing Process: Implementation MSC: CRNE: CH-sixty one
13. Which type of stroke is the maximum not unusual one, representing about 80% of all
strokes?
A. Intercerebral stroke
b. Ischemic stroke
c. Hemorrhagic stroke
d. Subarachnoid stroke - ANS-ANS: B
Ischemic strokes account for approximately 80% of all strokes.
PTS: 1 DIF: Cognitive Level: Knowledge REF: web page 1676
OBJ: 1 TOP: Nursing Process: Assessment MSC: CRNE: CH-8
14. A patient with homonymous hemianopsia due to a stroke has a nursing diagnosis of
disturbed sensory notion related to hemianopsia. What is the correct nursing intervention with a
view to assist the affected person discover ways to atone for the deficit at some point of the
rehabilitation period?
A. Apply an eye patch to the affected eye.
B. Approach the patient at the unaffected side.
C. Place items necessary for activities of daily living on the affected aspect.
D. Teach the patient to exercise the eye muscular tissues with full variety of movement at the
least two times a day. - ANS-ANS: C
During the rehabilitation period, placing gadgets at the affected side will inspire the affected
person to use the scanning approach to visualize the affected facet.
PTS: 1 DIF: Cognitive Level: Application REF: page 1694
OBJ: 8 TOP: Nursing Process: Implementation MSC: CRNE: CH-seventy seven
Stroke Lewis et al.: Medical-Surgical
Nursing in Canada, 3rd Edition
1. The nurse obtains all the following records approximately a sixty five-12 months-vintage
patient within the medical institution. When growing a plan to lower stroke hazard, which hazard
factor is most crucial for the nurse to cope with?
A. The affected person smokes a percent of cigarettes each day.
B. The affected person's blood pressure is chronically among a hundred and fifty/80 and one
hundred seventy/ninety mm Hg.
C. The patient works at a table and relaxes with the aid of watching tv.
D. The patient is 11.Three kg above the perfect weight. - ANS-ANS: B
Hypertension is the maximum important modifiable risk issue.
PTS: 1 DIF: Cognitive Level: Application REF: page 1674
OBJ: 1 TOP: Nursing Process: Planning MSC: CRNE: HW-2
10. A 68-yr-vintage guy has had numerous TIAs with transient hemiparesis and dysarthria which
have lasted as much as an hour. The nurse encourages the affected person to seek immediate
clinical help for any symptoms that remaining longer than an hour, explaining that permanent
incapacity from a stroke may be reduced if remedy is initiated within 3 hours with using which of
the subsequent treatments?
A. IV heparin
b. Transluminal angioplasty
c. A surgical endarterectomy
d. TPA - ANS-ANS: D
The affected person's history and scientific manifestations suggest an acute ischemic stroke,
and a patient who's visible within three hours of stroke onset is in all likelihood to get hold of tPA
(after screening with a CT experiment).
PTS: 1 DIF: Cognitive Level: Comprehension REF: page 1683
OBJ: 7 TOP: Nursing Process: Implementation MSC: CRNE: CH-sixty one
eleven. The nurse identifies the nursing analysis of impaired verbal verbal exchange for a
affected person with expressive aphasia. What is the best nursing intervention to help the
patient talk?
A. Ask easy questions that can be responded with "yes" or "no."
b. Develop a listing of simple phrases that she can study and coaching reciting.
C. Have her training facial and tongue physical games to improve motor manipulate vital for
speech.
, D. Prevent embarrassing her through changing the difficulty if she does no longer reply in a well
timed way. - ANS-ANS: A
Communication can be facilitated and much less irritating to the patient whilst questions that
require a "sure" or "no" reaction are used.
PTS: 1 DIF: Cognitive Level: Application REF: web page 1692, Table 60-9
OBJ: 7 TOP: Nursing Process: Implementation MSC: CRNE: NCP-2
12. Twenty-four hours after admission, a affected person with a stroke has revolutionary
improvement of neurological deficits with increasing weak spot and reduced level of attention.
What is the primary goal of nursing control of the affected person at the moment?
A. Protecting the pores and skin from breakdown
b. Monitoring for adjustments in neurological repute
c. Maintaining the affected person's breathing characteristic
d. Preventing joint contractures and muscle atrophy - ANS-ANS: C
Protection of the airway is the priority of nursing take care of a affected person having an acute
stroke.
PTS: 1 DIF: Cognitive Level: Comprehension REF: web page 1687
OBJ: 7 TOP: Nursing Process: Implementation MSC: CRNE: CH-sixty one
13. Which type of stroke is the maximum not unusual one, representing about 80% of all
strokes?
A. Intercerebral stroke
b. Ischemic stroke
c. Hemorrhagic stroke
d. Subarachnoid stroke - ANS-ANS: B
Ischemic strokes account for approximately 80% of all strokes.
PTS: 1 DIF: Cognitive Level: Knowledge REF: web page 1676
OBJ: 1 TOP: Nursing Process: Assessment MSC: CRNE: CH-8
14. A patient with homonymous hemianopsia due to a stroke has a nursing diagnosis of
disturbed sensory notion related to hemianopsia. What is the correct nursing intervention with a
view to assist the affected person discover ways to atone for the deficit at some point of the
rehabilitation period?
A. Apply an eye patch to the affected eye.
B. Approach the patient at the unaffected side.
C. Place items necessary for activities of daily living on the affected aspect.
D. Teach the patient to exercise the eye muscular tissues with full variety of movement at the
least two times a day. - ANS-ANS: C
During the rehabilitation period, placing gadgets at the affected side will inspire the affected
person to use the scanning approach to visualize the affected facet.
PTS: 1 DIF: Cognitive Level: Application REF: page 1694
OBJ: 8 TOP: Nursing Process: Implementation MSC: CRNE: CH-seventy seven
