Nur 242 exam 4
Which intervention would the disaster management team nurse perform for the
survivors of an explosion who developed heat stroke? - ANSWER-Apply ice packs on
the client's scalp
Which level of care is the nurse providing when preparing to discharge a client who is
learning to walk again after a stroke to a rehabilitation center? - ANSWER-tertiary care
Which action by the emergency department nurse is the priority for a client with heat
stroke? - ANSWER-Assess the airway and breathing
A client who sustains a stroke has a loss of proprioception and fine touch. Which artery
would the nurse suspect is damaged? - ANSWER-Anterior cerebral
A client has a brain attack (stroke) that involves the right cerebral cortex and cranial
nerves. Which areas of paralysis would the nurse expect to find upon assessment?
Select all that apply. One, some, or all responses may be correct. - ANSWER-Left leg
Left arm
Left side of face
Initially after a stroke, a client's pupils are equal and reactive to light. Later, the nurse
assesses that the right pupil is reacting more slowly than the left and that the systolic
blood pressure is rising. Which complication would the nurse plan to address? -
ANSWER-Increased intracranial pressure
The registered nurse (RN) is caring for a client who is currently hospitalized for a stroke.
Which professional management strategy will be most effective for the RN to improve
the safety and quality of client care? - ANSWER-Delegation
The client taking intravenous coagulant medications for a bleeding disorder suddenly
develops an embolic stroke as a result of medication overdose. Which actions by the
hospital management does the Leapfrog Group suggest? Select all that apply. One,
some, or all responses may be correct. - ANSWER-Apologize to the client and family.
Waive all costs directly related to the adverse effect.
Report the adverse event to The Joint Commission.
,The nurse is planning care for an immobilized client who had a stroke with right-sided
hemiparesis. Which activity would the nurse include in the plan of care? - ANSWER-
Assist the client to perform range-of-motion (ROM) exercises every 1 to 2 hours
Which is the priority nursing action for a client admitted to the hospital in a coma after
having a stroke? - ANSWER-Maintain an open airway.
Which position would the nurse plan to use for the client who is having a hypertensive
crisis and evolving stroke? - ANSWER-Side-lying
Which nursing action is essential when a client experiences hemianopsia as the result
of a left ischemic stroke? - ANSWER-Place objects within the visual field
Which action will the nurse complete when preparing a stroke client for cerebral imaging
with iodine-based contrast dye? - ANSWER-Ensure a recent creatinine level has been
assessed.
Which behaviors would the nurse include when teaching a family what to expect from a
client who experienced a stroke on the left side of the brain? Select all that apply. One,
some, or all responses may be correct. - ANSWER-Slow performance and caution
Impaired speech/language aphasias
Awareness of deficits with depression and anxiety
When a client has difficulty swallowing after a stroke, which action by the nurse would
be most important in preventing pneumonia? - ANSWER-Having suction available
during meals
A client has had a recent brain attack (cerebrovascular accident/stroke). Which
preventative would the nurse anticipate will be prescribed daily to avoid straining due to
constipation? - ANSWER-Stool softener
Initially after a stroke, the client's pupils are equal and reactive to light. Four hours later,
the nurse identifies that one pupil reacts more slowly than the other and the client's
systolic blood pressure is increasing. For which condition would the nurse prepare to
intervene? - ANSWER-Increased intracranial pressure
The nurse observes dorsiflexion of the big toe and fanning of other toes when the lateral
side of a client's foot is stroked. Which finding would the nurse document? - ANSWER-
Exhibits a positive Babinski sign
The nurse is caring for a client who had a stroke and who has varying moods ranging
from anger to depression to concern about the aphasia, hemiparesis, and the gavage
feedings. Which behavior indicates the client's acceptance of physical limitations? -
ANSWER-Performs tube feedings without assistance
, A client has dysarthria after a stroke. Which goal would the nurse include in the plan of
care to address this problem? - ANSWER-Effective communication
Which reflex is the nurse testing when using a dull object to stroke from the lateral sole
of a client's foot upward to the great toe? - ANSWER-Babinski
A client admitted to the hospital with the diagnosis of a right-sided "brain attack" (stroke)
is right-handed. Which task will be most difficult for this client? - ANSWER-Dressing
every morning
The nurse assessed a client who experienced a recent brain attack (stroke) and has a
residual right-sided hemiplegia. Which rationale explains the importance of the nurse
identifying mobility restrictions or neuromuscular abnormalities when assessing this
client? - ANSWER-Shortening and eventual atrophy of the affected muscles will occur
Which condition of a client with hemorrhagic stroke resulting from a motor bike accident
requires immediate attention? - ANSWER-Body temperature of 81.2°F
In which order would the nurse caring for a client suffering from heatstroke provide
emergency interventions? - ANSWER-Ensure a patent airway.
Remove the client from the hot environment.
Remove the client's clothing
Pour or spray cold water on the client's body and scalp.
Fan the client with newspapers or whatever is available.
Place ice in cloth or bags and position the packs on the client's scalp
Emergency care should be provided to the client with heatstroke to restore
thermoregulation. First the nurse would ensure a patent airway. Then the nurse would
remove the client from the hot environment into air conditioning or shade and remove
his or her clothing. Then the nurse would pour or spray cold water on the client's body
and scalp. The client should be fanned with newspapers or whatever is available. This
should be followed by placing ice in cloth or bags and positioning the packs on the
client's scalp.
Which priority interventions would the nurse provide to the client hospitalized with
heatstroke, a body temperature of 106°F, and skin that is hot and dry? Select all that
apply. One, some, or all responses may be correct - ANSWER-Remove the client's
clothing.
Immerse the client in cold water
Which nursing intervention is the priority for a client with stroke who is transitioned from
the emergency department (ED) to other settings? - ANSWER-Assessing the level of
consciousnes
Which client condition requires a medium priority of care according to the National
Institutes of Health Stroke Scale (NIHSS) score? - ANSWER-Facial palsy score of 1
Which intervention would the disaster management team nurse perform for the
survivors of an explosion who developed heat stroke? - ANSWER-Apply ice packs on
the client's scalp
Which level of care is the nurse providing when preparing to discharge a client who is
learning to walk again after a stroke to a rehabilitation center? - ANSWER-tertiary care
Which action by the emergency department nurse is the priority for a client with heat
stroke? - ANSWER-Assess the airway and breathing
A client who sustains a stroke has a loss of proprioception and fine touch. Which artery
would the nurse suspect is damaged? - ANSWER-Anterior cerebral
A client has a brain attack (stroke) that involves the right cerebral cortex and cranial
nerves. Which areas of paralysis would the nurse expect to find upon assessment?
Select all that apply. One, some, or all responses may be correct. - ANSWER-Left leg
Left arm
Left side of face
Initially after a stroke, a client's pupils are equal and reactive to light. Later, the nurse
assesses that the right pupil is reacting more slowly than the left and that the systolic
blood pressure is rising. Which complication would the nurse plan to address? -
ANSWER-Increased intracranial pressure
The registered nurse (RN) is caring for a client who is currently hospitalized for a stroke.
Which professional management strategy will be most effective for the RN to improve
the safety and quality of client care? - ANSWER-Delegation
The client taking intravenous coagulant medications for a bleeding disorder suddenly
develops an embolic stroke as a result of medication overdose. Which actions by the
hospital management does the Leapfrog Group suggest? Select all that apply. One,
some, or all responses may be correct. - ANSWER-Apologize to the client and family.
Waive all costs directly related to the adverse effect.
Report the adverse event to The Joint Commission.
,The nurse is planning care for an immobilized client who had a stroke with right-sided
hemiparesis. Which activity would the nurse include in the plan of care? - ANSWER-
Assist the client to perform range-of-motion (ROM) exercises every 1 to 2 hours
Which is the priority nursing action for a client admitted to the hospital in a coma after
having a stroke? - ANSWER-Maintain an open airway.
Which position would the nurse plan to use for the client who is having a hypertensive
crisis and evolving stroke? - ANSWER-Side-lying
Which nursing action is essential when a client experiences hemianopsia as the result
of a left ischemic stroke? - ANSWER-Place objects within the visual field
Which action will the nurse complete when preparing a stroke client for cerebral imaging
with iodine-based contrast dye? - ANSWER-Ensure a recent creatinine level has been
assessed.
Which behaviors would the nurse include when teaching a family what to expect from a
client who experienced a stroke on the left side of the brain? Select all that apply. One,
some, or all responses may be correct. - ANSWER-Slow performance and caution
Impaired speech/language aphasias
Awareness of deficits with depression and anxiety
When a client has difficulty swallowing after a stroke, which action by the nurse would
be most important in preventing pneumonia? - ANSWER-Having suction available
during meals
A client has had a recent brain attack (cerebrovascular accident/stroke). Which
preventative would the nurse anticipate will be prescribed daily to avoid straining due to
constipation? - ANSWER-Stool softener
Initially after a stroke, the client's pupils are equal and reactive to light. Four hours later,
the nurse identifies that one pupil reacts more slowly than the other and the client's
systolic blood pressure is increasing. For which condition would the nurse prepare to
intervene? - ANSWER-Increased intracranial pressure
The nurse observes dorsiflexion of the big toe and fanning of other toes when the lateral
side of a client's foot is stroked. Which finding would the nurse document? - ANSWER-
Exhibits a positive Babinski sign
The nurse is caring for a client who had a stroke and who has varying moods ranging
from anger to depression to concern about the aphasia, hemiparesis, and the gavage
feedings. Which behavior indicates the client's acceptance of physical limitations? -
ANSWER-Performs tube feedings without assistance
, A client has dysarthria after a stroke. Which goal would the nurse include in the plan of
care to address this problem? - ANSWER-Effective communication
Which reflex is the nurse testing when using a dull object to stroke from the lateral sole
of a client's foot upward to the great toe? - ANSWER-Babinski
A client admitted to the hospital with the diagnosis of a right-sided "brain attack" (stroke)
is right-handed. Which task will be most difficult for this client? - ANSWER-Dressing
every morning
The nurse assessed a client who experienced a recent brain attack (stroke) and has a
residual right-sided hemiplegia. Which rationale explains the importance of the nurse
identifying mobility restrictions or neuromuscular abnormalities when assessing this
client? - ANSWER-Shortening and eventual atrophy of the affected muscles will occur
Which condition of a client with hemorrhagic stroke resulting from a motor bike accident
requires immediate attention? - ANSWER-Body temperature of 81.2°F
In which order would the nurse caring for a client suffering from heatstroke provide
emergency interventions? - ANSWER-Ensure a patent airway.
Remove the client from the hot environment.
Remove the client's clothing
Pour or spray cold water on the client's body and scalp.
Fan the client with newspapers or whatever is available.
Place ice in cloth or bags and position the packs on the client's scalp
Emergency care should be provided to the client with heatstroke to restore
thermoregulation. First the nurse would ensure a patent airway. Then the nurse would
remove the client from the hot environment into air conditioning or shade and remove
his or her clothing. Then the nurse would pour or spray cold water on the client's body
and scalp. The client should be fanned with newspapers or whatever is available. This
should be followed by placing ice in cloth or bags and positioning the packs on the
client's scalp.
Which priority interventions would the nurse provide to the client hospitalized with
heatstroke, a body temperature of 106°F, and skin that is hot and dry? Select all that
apply. One, some, or all responses may be correct - ANSWER-Remove the client's
clothing.
Immerse the client in cold water
Which nursing intervention is the priority for a client with stroke who is transitioned from
the emergency department (ED) to other settings? - ANSWER-Assessing the level of
consciousnes
Which client condition requires a medium priority of care according to the National
Institutes of Health Stroke Scale (NIHSS) score? - ANSWER-Facial palsy score of 1
