hh4 test 2 Questions With Complete Solutions
The charge nurse is teaching a nursing student about immediate
stroke care. Which of the following information should the nurse
share with the nursing student?
a. Hypotension post stroke is normal.
b. Antihypertensive medication is administered if the mean
arterial pressure is >130 mm Hg.
c. Diuretics are ordered in the systolic BP is >160 mm Hg.
d. Withholding medications until the degree of dysphasia is
known.
B
Elevated BP is common immediately after a stroke and may be a
protective response to maintain cerebral perfusion. Immediately
following ischemic stroke, use of drugs to lower BP is
recommended only if BP is markedly increased (mean arterial
pressure >130 mm Hg or systolic BP > 220 mm Hg).
Withholding medications can be dangerous; medications do not
have to be given by the oral route.
The nurse is caring for a patient who had a stroke and is in the
acute phase of care. Which of the following systems is priority?
a. Neurological system
b. Respiratory system
c. Gastrointestinal system
d. Genitourinary system
B
During the acute phase following a stroke, management of the
,respiratory system is a nursing priority. Stroke patients are
particularly vulnerable to respiratory problem as it has been
shown that respiratory muscle strength decreases following
stroke. Advancing age and immobility increase the risk for
atelectasis and pneumonia.
The nurse is admitting a patient with left-sided hemiparesis who
has arrived by ambulance to the emergency department. Which
of the following actions should the nurse take first?
Check the respiratory rate.
Monitor the blood pressure.
Send the patient for a CT scan.
Obtain the Glasgow Coma Scale score.
ANS: A
The initial nursing action should be to assess the airway and take
any needed actions to ensure a patent airway. The other
activities should take place quickly after the CABs (circulation,
airway, breathing) are completed.
The nurse is admitting a patient who began experiencing right-
sided arm and leg weakness to
the emergency department. Which of the following actions
should the nurse implement first?
a. Obtain CT scan without contrast.
b. Infuse tissue plasminogen activator (tPA).
c. Administer oxygen to keep O2 saturation >95%.
d. Use National Institute of Health Stroke Scale to assess patient.
,C
The initial action should be to administer oxygen-priority is for
those actions that help with circulation, airway, and breathing.
Baseline neurologic assessments should be done next. A CT
scan will be needed to rule out hemorrhagic stroke before tPA
can be administered.
The nurse is teaching a patient about management of migraine
headaches. Which of the
following patient statements indicate that the teaching has been
effective?
a. "I will take the topiramate as soon as any headaches start."
b. "I should avoid taking Aspirin and sumatriptan at the same
time."
c. "I will try to lie down in a dark and quiet area when the
headaches begin."
d. "A glass of wine might help me relax and prevent headaches
from developing."
C
It is recommended that the patient with a migraine rest in a dark,
quiet area. Topiramate is used to prevent migraines and must be
taken for several months to determine effectiveness. Aspirin or
other nonsteroidal anti-inflammatory medications can be taken
with the triptans. Alcohol may precipitate migraine headaches.
Which of the following parameters should the nurse assess when
caring for a patient who is
experiencing a cluster headache?
a. Nuchal rigidity
, b. Projectile vomiting
c. Unilateral eyelid swelling
d. Throbbing, bilateral facial pain
C
Unilateral eye edema, tearing, and ptosis are characteristics of
cluster headaches. Nuchal rigidity suggests meningeal irritation,
such as occurs with meningitis. Although nausea and vomiting
may occur with migraine headaches, projectile vomiting is more
consistent with increases in intracranial pressure (ICP).
Unilateral sharp, stabbing pain, rather than throbbing pain, is
characteristic of cluster headaches.
A patient has a tonic-clonic seizure while the nurse is in the
patient's room. Which of the
following actions should the nurse take?
a. Insert an oral airway during the seizure to maintain a patent
airway.
b. Restrain the patient's arms and legs to prevent injury during
the seizure.
c. Avoid touching the patient to prevent further nervous system
stimulation.
d. Time and observe and record the details of the seizure and
postictal state.
D
Because diagnosis and treatment of seizures frequently are based
on the description of the seizure, recording the length and details
of the seizure is important. Insertion of an oral airway and
restraining the patient during the seizure are contraindicated.
The charge nurse is teaching a nursing student about immediate
stroke care. Which of the following information should the nurse
share with the nursing student?
a. Hypotension post stroke is normal.
b. Antihypertensive medication is administered if the mean
arterial pressure is >130 mm Hg.
c. Diuretics are ordered in the systolic BP is >160 mm Hg.
d. Withholding medications until the degree of dysphasia is
known.
B
Elevated BP is common immediately after a stroke and may be a
protective response to maintain cerebral perfusion. Immediately
following ischemic stroke, use of drugs to lower BP is
recommended only if BP is markedly increased (mean arterial
pressure >130 mm Hg or systolic BP > 220 mm Hg).
Withholding medications can be dangerous; medications do not
have to be given by the oral route.
The nurse is caring for a patient who had a stroke and is in the
acute phase of care. Which of the following systems is priority?
a. Neurological system
b. Respiratory system
c. Gastrointestinal system
d. Genitourinary system
B
During the acute phase following a stroke, management of the
,respiratory system is a nursing priority. Stroke patients are
particularly vulnerable to respiratory problem as it has been
shown that respiratory muscle strength decreases following
stroke. Advancing age and immobility increase the risk for
atelectasis and pneumonia.
The nurse is admitting a patient with left-sided hemiparesis who
has arrived by ambulance to the emergency department. Which
of the following actions should the nurse take first?
Check the respiratory rate.
Monitor the blood pressure.
Send the patient for a CT scan.
Obtain the Glasgow Coma Scale score.
ANS: A
The initial nursing action should be to assess the airway and take
any needed actions to ensure a patent airway. The other
activities should take place quickly after the CABs (circulation,
airway, breathing) are completed.
The nurse is admitting a patient who began experiencing right-
sided arm and leg weakness to
the emergency department. Which of the following actions
should the nurse implement first?
a. Obtain CT scan without contrast.
b. Infuse tissue plasminogen activator (tPA).
c. Administer oxygen to keep O2 saturation >95%.
d. Use National Institute of Health Stroke Scale to assess patient.
,C
The initial action should be to administer oxygen-priority is for
those actions that help with circulation, airway, and breathing.
Baseline neurologic assessments should be done next. A CT
scan will be needed to rule out hemorrhagic stroke before tPA
can be administered.
The nurse is teaching a patient about management of migraine
headaches. Which of the
following patient statements indicate that the teaching has been
effective?
a. "I will take the topiramate as soon as any headaches start."
b. "I should avoid taking Aspirin and sumatriptan at the same
time."
c. "I will try to lie down in a dark and quiet area when the
headaches begin."
d. "A glass of wine might help me relax and prevent headaches
from developing."
C
It is recommended that the patient with a migraine rest in a dark,
quiet area. Topiramate is used to prevent migraines and must be
taken for several months to determine effectiveness. Aspirin or
other nonsteroidal anti-inflammatory medications can be taken
with the triptans. Alcohol may precipitate migraine headaches.
Which of the following parameters should the nurse assess when
caring for a patient who is
experiencing a cluster headache?
a. Nuchal rigidity
, b. Projectile vomiting
c. Unilateral eyelid swelling
d. Throbbing, bilateral facial pain
C
Unilateral eye edema, tearing, and ptosis are characteristics of
cluster headaches. Nuchal rigidity suggests meningeal irritation,
such as occurs with meningitis. Although nausea and vomiting
may occur with migraine headaches, projectile vomiting is more
consistent with increases in intracranial pressure (ICP).
Unilateral sharp, stabbing pain, rather than throbbing pain, is
characteristic of cluster headaches.
A patient has a tonic-clonic seizure while the nurse is in the
patient's room. Which of the
following actions should the nurse take?
a. Insert an oral airway during the seizure to maintain a patent
airway.
b. Restrain the patient's arms and legs to prevent injury during
the seizure.
c. Avoid touching the patient to prevent further nervous system
stimulation.
d. Time and observe and record the details of the seizure and
postictal state.
D
Because diagnosis and treatment of seizures frequently are based
on the description of the seizure, recording the length and details
of the seizure is important. Insertion of an oral airway and
restraining the patient during the seizure are contraindicated.
