Chapter 28: Cerebrovascular Accident Linton: Introduction to Medical-Surgical Nursing, 6th Edition ALL ANSWERS 100% CORRECT SPRING FALL-2022 LATEST GUARANTEED GRADE 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. Patients complaint of nausea b. Blood pressure (BP) of 140/90 mm Hg c. Patients 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 toocommon 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 patients 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 maintenancec. Adequate hydration d. Control of elimination ANS: B Adequate oxygenation prevents hypoxemia, which can extend and worsen effects of the CVA. DIF: Cognitive Level: Application REF: p. 491 OBJ: 7 TOP: Nursing Care of Acute CVA KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 8. When should a nurse recognize that the acute phase of a CVA has ended? a. Forty-eight hours has passed from its onset. b. The patient begins to respond verbally. c. BP drops. d. Vital signs and neurologic signs stabilize. ANS: D When the vital and neurologic signs stabilize, the acute phase has ended. Verbal response, lower BP, and the passage of time without other signs are not adequate evidence that the acute phase has ended. DIF: Cognitive Level: Comprehension REF: p. 491 OBJ: 7 TOP: Acute Phase of CVA KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. A patient in the acute phase of a CVA who has been speaking distinctly begins to speak indistinctly and only with great effort but still coherent. What should this nurse determine when assessing this patient? a. Stroke in evolution with dysarthria b. Lacunar stroke with fluent aphasia c. Complete stroke with global aphasia d. Stroke in evolution with dyspraxia ANS: A As symptoms worsen, the CVA is still evolving. Speech that is coherent but difficult is dysarthria rather than any type of aphasia. Dyspraxia is a motor impairment, not a speech impairment. DIF: Cognitive Level: Analysis REF: p. 490 OBJ: 4 TOP: CVA Deficits KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 10. Several days after a CVA, a patients family asks a nurse if tissue plasminogen activator (tPA) is a drug therapy option now. The nurses response is based on the knowledge that this drug must be used within how many hours after the onset of symptoms? a. 3 b. 5 c. 10 d. 24 ANS: AtPA is to be given within 3 hours of the onset of symptoms per the U.S. Food and Drug Administrations guidelines. In some special treatment centers this drug is given intravenously up to 6 hours after the stroke. DIF: Cognitive Level: Knowledge REF: p. 492 OBJ: 6 TOP: CVA Medication Implementation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 11. A nurse explains that a lumbar puncture is most helpful as a diagnostic tool for a new patient who has had a CVA. What would this diagnostic test help determine regarding the stroke? a. It is lacunar. b. It is hemorrhagic or embolic. c. It is complete or in evolution. d. It will result in paralysis. ANS: B Blood in the spinal fluid indicates a hemorrhagic stroke and will help direct medical protocol in the subsequent treatment. DIF: Cognitive Level: Comprehension REF: p. 491 OBJ: 5 TOP: CVA Diagnostic Tests KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 12. A patient who has sustained a hemorrhagic stroke is placed on a protocol of 60 mg of calcium channel blocker (nimodipine) every 4 hours. The patients pulse is 82 beats/min before the administration of the prescribed dose. Which action should the nurse implement? a. Give the full dose as prescribed without further assessment. b. Omit the dose, recording the pulse rate as the rationale. c. Delay the dose until the pulse is below 60 beats/min. d. Give half of the prescribed dose (30 mg). ANS: A The dose should be given; it would be held only if the pulse is below 60 beats/min. Assessments should be made regarding BP, urine output, and edema. DIF: Cognitive Level: Application REF: p. 487 OBJ: 3 TOP: CVA Medical Protocol KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 13. During the acute CVA phase, a risk for falls related to paralysis is present. Which intervention best protects the patient from injury? a. Keep the bed in a high position for ease of nursing care. b. Keep the side rails up, according to agency policy. c. Assess vision deficit related to ptosis. d. Monitor the condition every 2 hours. ANS: B Rails keep patients in bed. The bed should be low, monitoring the patient should be more frequent than every 2 hours, and visual assessment is not directly related to fall prevention.DIF: Cognitive Level: Application REF: p. 495 OBJ: 8 TOP: Acute Care: Fall Prevention KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 14. Pneumonia is the most frequent cause of death after a stroke. Which intervention would be contraindicated in the acute care of a patient with a hemorrhagic CVA? a. Thicken liquids to ease swallowing and prevent aspiration. b. Change position every 30 to 60 minutes. c. Maintain adequate fluid intake, orally or IV. d. Encourage forceful coughing to stimulate deep breathing. ANS: D Forceful coughing is contraindicated for the patient with a hemorrhagic CVA because it may cause increased intracranial pressure. DIF: Cognitive Level: Comprehension REF: p. 497 OBJ: 8 TOP: Prevention of Pneumonia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 15. Which assessment indicates a fluid volume excess in a patient in the acute phase of a CVA? a. Decreased BP b. Weak pulse c. Adventitious breath sounds d. High urine-specific gravity ANS: C Crackles in the lung fields are a major indicator of fluid excess. The pulse and BP are elevated in fluid excess. Urine-specific gravity is low in fluid excess. DIF: Cognitive Level: Application REF: p. 499 OBJ: 8 TOP: Fluid Excess KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 16. Which intervention should the nurse include in a patients plan of care to help preserve joint mobility in the acute phase of a CVA? a. Pull the limbs on the affected side into a functional position. b. Perform aggressive full range-of-motion exercises for all extremities. c. Support affected points in good functional alignment. d. Exercise the limbs every 8 hours. ANS: C