A&C Exam 3 Strokes

A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include? - Encourage the client to take small bites. A nurse is caring for a client who has a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take? - Remind the client to look for food on the left side of the tray. A nurse in an emergency department is caring for a client who has a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38.2 C (100.8 F). Which of the following neurologic disorders should the nurse expect? - Hemorrhagic stroke A nurse is monitoring a client who has a cerebral aneurysm rupture. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure? - Irritability A nurse is shopping and finds a woman who has collapses with right-sided weakness and slurred speech. Which of the following actions should the nurse take? - Notify emergency management services. A nurse who is off duty finds a woman who has collapses and has right-sided weakness and slurred speech. Which of the following actions should the nurse take? - Call emergency services. A nurse is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate with the client. Which of the following responses by the nurse is appropriate? - Incorporate nonverbal cues in the conversation. A nurse is caring for a client who has atrial fibrillation and is receiving heparin. Which of the following findings is the nurse's priority? - The client experiences sudden weakness of one arm and leg. A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings? - Poor impulse control A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program? - Establish the ability to communicate effectively. A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority? - Suction saliva from the client's mouth. A nurse is caring for a client who had a stroke involving the left cerebral hemisphere. The nurse should monitor for which of the following findings? - Impaired sense of humor A nurse is teaching about risk factors of developing a stroke with a group of older adult clients. Which of the following nonmodifiable risk factors should the nurse include in the teaching? - Race A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse excpect? - Manifestations preceded by a severe headache. A 75-year-old man is admitted to the hospital with a possible cerebrovascular accident. Digital subtraction angiography (DSA) will be done to confirm the diagnosis. Which nursing action should be included in the preprocedure nursing care plan for this patient? - Determine allergy history. A 67-year-old woman suffering from a stroke has urinary incontinence with impaired impulse to void. Which intervention does the nurse plan as part of a bladder retraining program for the patient? - Assist the patient on to the bedpan or the bedside commode every two hours during the day. Concerning the pathophysiology of intracranial pressure, there is a theory that an increase in any one of the contents of the cranium is usually accompanied by a reciprocal change in the volume of one of the others. This is called: - Monro-Kelli Hypothesis.