NR 443 CHAPTER 28:
CEREBROVASCULAR ACCIDENT
Chapter 28: Cerebrovascular Accident
Linton: Introduction to Medical-Surgical Nursing, 6th Edition
MULTIPLE CHOICE
1. A patient has weakness on the right side and impaired reasoning after having a cerebrovascular
accident (CVA). What part of the brain is affected?
a. Left hemisphere of the cerebrum
b. Right hemisphere of the cerebrum
c. Left cerebellum
d. Right cerebellum
ANS: A
Impaired motor strength on the right side in conjunction with impaired reasoning indicates a lesion in
the left hemisphere of the cerebrum. The cerebellum controls balance and is not contralateral.
DIF: Cognitive Level: Comprehension REF: p. 481-482 OBJ: 3
TOP: Symptoms of a CVA KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. Which patient is at the greatest risk for a CVA?
a. A 20-year-old obese Latin woman who is taking birth control pills
b. A 40-year-old athletic white man with a family history of CVA
c. A 60-year-old Asian woman who smokes occasionally
d. A 65-year-old African American man with hypertension
ANS: D
Older African Americans have a higher incidence of CVA than occasional smokers, young persons,
or athletes. Hypertension increases the risk.
DIF: Cognitive Level: Analysis REF: p. 483 OBJ: 1
TOP: CVA Risk Factors KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
3. A patient experienced a period of momentary confusion, dizziness, and slurred speech but
recovered in 2 hours. Which assessment in the diagnosis of this episode would be most helpful?
a. Patient’s complaint of nausea
b. Blood pressure (BP) of 140/90 mm Hg
c. Patient’s complaint of headache
d. Auscultation of a bruit over the carotid artery
ANS: D
A carotid bruit is evidence of a narrowing in that vessel, a symptom of a possible CVA or transient
ischemic attack (TIA). BP of 140/90 mm Hg, although at the high end, is considered within normal
limits. Headache and nausea alone are too common to be definitive.
DIF: Cognitive Level: Application REF: p. 485 OBJ: 2
TOP: TIA Diagnosis KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
, 4. A nurse is updating a teaching plan for a patient who sustained a TIA. What should the nurse be
sure to include?
a. Daily aspirin dose
b. Long rest periods daily
c. Reduction of fluid intake to 800 mL/day
d. High-carbohydrate diet
ANS: A
Daily aspirin reduces platelet aggregation and may prevent another attack. Reductions of fluid and
long rest periods encourage clot formation.
DIF: Cognitive Level: Application REF: p. 485 OBJ: 3
TOP: Post-TIA Teaching KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
5. A patient recovering from a CVA asks the purpose of the warfarin (Coumadin). What is the best
response by the nurse regarding the purpose of Coumadin?
a. Dissolves the clot.
b. Prevents the formation of new clots.
c. Dilates the vessels to improve blood flow.
d. Suppresses the formation of platelets.
ANS: B
Coumadin and heparin prevent more clots rather than dissolving them. Coumadin has no effect on
vasodilation or blood cell production.
DIF: Cognitive Level: Comprehension REF: p. 486 OBJ: 3
TOP: Coumadin Therapy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
6. A patient has had a complete stroke as a result of a ruptured vessel in the left hemisphere. How
should this patient’s CVA be classified?
a. Ischemic, embolic
b. Hemorrhagic, subarachnoid
c. Hemorrhagic, intracerebral
d. Ischemic, thrombotic
ANS: C
A ruptured vessel in a hemisphere is an intracerebral hemorrhagic CVA. It did not occur in the
subarachnoid space. Ischemic CVAs are the result of occluded vessels.
DIF: Cognitive Level: Analysis REF: p. 487 OBJ: 2
TOP: CVA Classification KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
7. What should a nurse ensure as a priority for a patient immediately after a CVA?
a. Preservation of motor function
b. Airway maintenance
c. Adequate hydration
d. Control of elimination
ANS: B
Adequate oxygenation prevents hypoxemia, which can extend and worsen effects of the CVA.
CEREBROVASCULAR ACCIDENT
Chapter 28: Cerebrovascular Accident
Linton: Introduction to Medical-Surgical Nursing, 6th Edition
MULTIPLE CHOICE
1. A patient has weakness on the right side and impaired reasoning after having a cerebrovascular
accident (CVA). What part of the brain is affected?
a. Left hemisphere of the cerebrum
b. Right hemisphere of the cerebrum
c. Left cerebellum
d. Right cerebellum
ANS: A
Impaired motor strength on the right side in conjunction with impaired reasoning indicates a lesion in
the left hemisphere of the cerebrum. The cerebellum controls balance and is not contralateral.
DIF: Cognitive Level: Comprehension REF: p. 481-482 OBJ: 3
TOP: Symptoms of a CVA KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. Which patient is at the greatest risk for a CVA?
a. A 20-year-old obese Latin woman who is taking birth control pills
b. A 40-year-old athletic white man with a family history of CVA
c. A 60-year-old Asian woman who smokes occasionally
d. A 65-year-old African American man with hypertension
ANS: D
Older African Americans have a higher incidence of CVA than occasional smokers, young persons,
or athletes. Hypertension increases the risk.
DIF: Cognitive Level: Analysis REF: p. 483 OBJ: 1
TOP: CVA Risk Factors KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
3. A patient experienced a period of momentary confusion, dizziness, and slurred speech but
recovered in 2 hours. Which assessment in the diagnosis of this episode would be most helpful?
a. Patient’s complaint of nausea
b. Blood pressure (BP) of 140/90 mm Hg
c. Patient’s complaint of headache
d. Auscultation of a bruit over the carotid artery
ANS: D
A carotid bruit is evidence of a narrowing in that vessel, a symptom of a possible CVA or transient
ischemic attack (TIA). BP of 140/90 mm Hg, although at the high end, is considered within normal
limits. Headache and nausea alone are too common to be definitive.
DIF: Cognitive Level: Application REF: p. 485 OBJ: 2
TOP: TIA Diagnosis KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
, 4. A nurse is updating a teaching plan for a patient who sustained a TIA. What should the nurse be
sure to include?
a. Daily aspirin dose
b. Long rest periods daily
c. Reduction of fluid intake to 800 mL/day
d. High-carbohydrate diet
ANS: A
Daily aspirin reduces platelet aggregation and may prevent another attack. Reductions of fluid and
long rest periods encourage clot formation.
DIF: Cognitive Level: Application REF: p. 485 OBJ: 3
TOP: Post-TIA Teaching KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
5. A patient recovering from a CVA asks the purpose of the warfarin (Coumadin). What is the best
response by the nurse regarding the purpose of Coumadin?
a. Dissolves the clot.
b. Prevents the formation of new clots.
c. Dilates the vessels to improve blood flow.
d. Suppresses the formation of platelets.
ANS: B
Coumadin and heparin prevent more clots rather than dissolving them. Coumadin has no effect on
vasodilation or blood cell production.
DIF: Cognitive Level: Comprehension REF: p. 486 OBJ: 3
TOP: Coumadin Therapy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
6. A patient has had a complete stroke as a result of a ruptured vessel in the left hemisphere. How
should this patient’s CVA be classified?
a. Ischemic, embolic
b. Hemorrhagic, subarachnoid
c. Hemorrhagic, intracerebral
d. Ischemic, thrombotic
ANS: C
A ruptured vessel in a hemisphere is an intracerebral hemorrhagic CVA. It did not occur in the
subarachnoid space. Ischemic CVAs are the result of occluded vessels.
DIF: Cognitive Level: Analysis REF: p. 487 OBJ: 2
TOP: CVA Classification KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
7. What should a nurse ensure as a priority for a patient immediately after a CVA?
a. Preservation of motor function
b. Airway maintenance
c. Adequate hydration
d. Control of elimination
ANS: B
Adequate oxygenation prevents hypoxemia, which can extend and worsen effects of the CVA.
