Chapter 62 Management of Patients With Cerebrovascular
Disorders
Multiple Choice
1. A patient is on the floor for monitoring after being admitted following an ischemic stroke.
The nurse who knows the importance of the principles of body alignment and correct
positioning will prevent joint deformities by:
A) Placing the patient in the prone position, laying flat, for 30 minutes a day
B) Assisting the patient in acutely flexing the thigh to promote movement
C) Placing a pillow in the axilla when there is limited external rotation
D) Placing the patient's hand in pronation
Ans: C
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 4
Patient Needs: A-1
Feedback: A pillow in the axilla prevents adduction of the affected shoulder and keeps the arm
away from the chest. The prone position with a pillow under the pelvis (not flat) promotes
hyperextension of the hip joints, which is essential for normal gait. To promote venous return
and prevent edema, the upper thigh should not be flexed acutely. The hand is placed in slight
supination, not pronation, which is its most functional position.
2. A patient who just suffered a hemorrhagic stroke is admitted through the emergency room.
The nurse's primary assessment is focused on:
A) Cardiac and respiratory status
B) Seizure activity
C) Urinary output
,D) Fluid and electrolyte balance
Ans: A
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 4
Patient Needs: A-1
Feedback: Acute care begins with managing the ABCs. Patients may have difficulty keeping an
open and clear airway secondary to a decreased level of consciousness. Neurological assessment
with close monitoring for signs of increased neurological deficit and seizure activity occurs next.
Fluid and electrolyte balance must be controlled carefully with a goal of adequate hydration to
promote perfusion and decrease further brain activity.
3. The nurse is caring for a patient on t-PA (tissue plasminogen activation) administration. The
most common side effect of this infusion is:
A) Bleeding
B) Hypertension
C) Migraine headache
D) Flaccid paralysis
Ans: A
Cognitive Level: Knowledge
Difficulty: Easy
Integrated Process: Nursing Process
Objective: 4
Patient Needs: A-1
,Feedback: The most common side effect of t-PA is bleeding because thrombolytic agents, like
t- PA, dissolve the blood clot that is blocking blood flow to the brain.
4. The nurse is aware that an absolute contraindication for thrombolytic therapy is seen in a
patient:
A) Who is anticoagulated
B) Who is hypertensive
C) With evidence of stroke evolution
D) With symptom onset of less than 3 hours prior to admission
Ans: A
Cognitive Level: Application
Difficulty: Moderate
, Integrated Process: Nursing Process
Objective: 4
Patient Needs: A-1
Feedback: A patient who is anticoagulated would be at too high a risk for bleeding; thrombolytic
therapy must occur within 3 hours of onset of symptoms due to revascularization of necrotic
tissue which increases the risk for cerebral edema and hemorrhage.
5. A patient experiencing transient ischemic attacks (TIAs) is scheduled for a carotid
endarterectomy. The nurse explains that this procedure will be done to:
A) Decrease cerebral edema
B) Prevent seizure activity that is common following a TIA
C) Prevent a stroke by removing atherosclerotic plaques blocking cerebral flow
D) Determine the cause of the TIA Ans: C
Cognitive Level: Knowledge
Difficulty: Easy
Integrated Process: Teaching/Learning
Objective: 3
Patient Needs: D-1
Feedback: The main surgical procedure for select patients with TIAs is carotid endarterectomy,
the removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in
patients with occlusive disease of the extracranial arteries.
6. The nurse is caring for a patient who had a stroke. Maintenance of reduced intracranial
pressure (ICP) is a priority with this patient. Which of the following positions is indicated to
assist with this goal?
A) Head turned to the right side
B) Elevation of the head of the bed
Disorders
Multiple Choice
1. A patient is on the floor for monitoring after being admitted following an ischemic stroke.
The nurse who knows the importance of the principles of body alignment and correct
positioning will prevent joint deformities by:
A) Placing the patient in the prone position, laying flat, for 30 minutes a day
B) Assisting the patient in acutely flexing the thigh to promote movement
C) Placing a pillow in the axilla when there is limited external rotation
D) Placing the patient's hand in pronation
Ans: C
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 4
Patient Needs: A-1
Feedback: A pillow in the axilla prevents adduction of the affected shoulder and keeps the arm
away from the chest. The prone position with a pillow under the pelvis (not flat) promotes
hyperextension of the hip joints, which is essential for normal gait. To promote venous return
and prevent edema, the upper thigh should not be flexed acutely. The hand is placed in slight
supination, not pronation, which is its most functional position.
2. A patient who just suffered a hemorrhagic stroke is admitted through the emergency room.
The nurse's primary assessment is focused on:
A) Cardiac and respiratory status
B) Seizure activity
C) Urinary output
,D) Fluid and electrolyte balance
Ans: A
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 4
Patient Needs: A-1
Feedback: Acute care begins with managing the ABCs. Patients may have difficulty keeping an
open and clear airway secondary to a decreased level of consciousness. Neurological assessment
with close monitoring for signs of increased neurological deficit and seizure activity occurs next.
Fluid and electrolyte balance must be controlled carefully with a goal of adequate hydration to
promote perfusion and decrease further brain activity.
3. The nurse is caring for a patient on t-PA (tissue plasminogen activation) administration. The
most common side effect of this infusion is:
A) Bleeding
B) Hypertension
C) Migraine headache
D) Flaccid paralysis
Ans: A
Cognitive Level: Knowledge
Difficulty: Easy
Integrated Process: Nursing Process
Objective: 4
Patient Needs: A-1
,Feedback: The most common side effect of t-PA is bleeding because thrombolytic agents, like
t- PA, dissolve the blood clot that is blocking blood flow to the brain.
4. The nurse is aware that an absolute contraindication for thrombolytic therapy is seen in a
patient:
A) Who is anticoagulated
B) Who is hypertensive
C) With evidence of stroke evolution
D) With symptom onset of less than 3 hours prior to admission
Ans: A
Cognitive Level: Application
Difficulty: Moderate
, Integrated Process: Nursing Process
Objective: 4
Patient Needs: A-1
Feedback: A patient who is anticoagulated would be at too high a risk for bleeding; thrombolytic
therapy must occur within 3 hours of onset of symptoms due to revascularization of necrotic
tissue which increases the risk for cerebral edema and hemorrhage.
5. A patient experiencing transient ischemic attacks (TIAs) is scheduled for a carotid
endarterectomy. The nurse explains that this procedure will be done to:
A) Decrease cerebral edema
B) Prevent seizure activity that is common following a TIA
C) Prevent a stroke by removing atherosclerotic plaques blocking cerebral flow
D) Determine the cause of the TIA Ans: C
Cognitive Level: Knowledge
Difficulty: Easy
Integrated Process: Teaching/Learning
Objective: 3
Patient Needs: D-1
Feedback: The main surgical procedure for select patients with TIAs is carotid endarterectomy,
the removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in
patients with occlusive disease of the extracranial arteries.
6. The nurse is caring for a patient who had a stroke. Maintenance of reduced intracranial
pressure (ICP) is a priority with this patient. Which of the following positions is indicated to
assist with this goal?
A) Head turned to the right side
B) Elevation of the head of the bed
