Test Bank For Medical-Surgical Nursing 10th Edition By Donna
Ignatavicius, M. Linda Workman 9780323612425 Chapter 1-69
Complete Guide .
Which finding could help the health care team differentiate a TIA from a stroke?
a. Pt has a unilateral facial droop
b. Pt has slurred speech
c. Symptoms resolve in 30-60 mins
d. ECG is normal - ANSWER: c. Symptoms resolve in 30-60 mins
The nurse is preparing to discharge a pt with transient ischemic attacks. What topics does the nurse
include in discharge teaching? Select all that apply.
a. Reduction of high blood pressure
b. Drug teaching for aspirin or other antiplatelet drug
c. Lifestyle changes such as smoking cessation
d. Self-care for managing chronic conditions such as diabetes
e. Increased risk fro stroke and signs/symptoms
f. Benefits of taking vitamin supplements - ANSWER: a. Reduction of high blood pressure
b. Drug teaching for aspirin or other antiplatelet drug
c. Lifestyle changes such as smoking cessation
d. Self-care for managing chronic conditions such as diabetes
e. Increased risk fro stroke and signs/symptoms
The home health nurse is assessing a pt who had a stroke that affected the right hemisphere. What
would the nurse expect to observe?
a. Pt is overly anxious and cautious when asked to do a new task.
b. Pt is euphoric and smiling but disoriented to person, place and time.
c. Pt is depressed and expresses ongoing worries about the future
d. Pt has a flat affect but is able to answer most questions appropriately. - ANSWER: b. Pt is euphoric
and smiling but disoriented to person, place and time.
The nurse is assessing a pt who was brought to the ED for altered mental status. In the absence of
family members or witnesses to give a history, what does the nurse do to identify two conditions that
could mimic emergent neurologic conditions?
a. Check skin turgor and perform a bladder scan
b. Check blood glucose and oxygen saturation
c. Observe for jugular vein distention and pitting edema
d. Observe for jaundice and abdominal distention - ANSWER: b. Check blood glucose and oxygen
saturation
Following a left cerebral hemisphere stroke, the pt has expressive (Broca's) aphasia. Which
intervention is best to use when communicating with this patient?
a. Repeat the names of objects on a routine basis.
b. Face the pt and speak slowly and clearly
c. Obtain a whiteboard with an erasable marker
d. Use a picture board that displays objects and activities.. - ANSWER: d. Use a picture board that
displays objects and activities..
,The nurse is caring for a pt with right cerebral hemisphere damage. The pt demonstrates
disorientation to time and place and neglect of the left visual field, and he has poor depth perception.
Which task is best delegated to the UAP?
a. Move the pt's bed so that his affected side faces the door
b. Teach the pt to wash both sides of his face
c. Ensure a safe environment by removing clutter
d. Suggest to the family tat they bring familiar family photos - ANSWER: c. Ensure a safe environment
by removing clutter
A pt with a right cerebral hemisphere stroke may have safety issues related to which factor?
a. Poor impulse control
b. Alexia and agraphia
c. Loss of language and analytical skills
d. Slow and cautious behavior - ANSWER: a. Poor impulse control
A stroke pt is at risk for increased intracranial pressure and is receiving 2 L via nasal cannula. The
nurse is reviewing ABG results. Which value is of greatest concern for this patient?
a. pH of 7.32
b. PaCO2 of 60
c. PaO2 of 95
d. HCO3 of 28 - ANSWER: b. PaCO2 of 60
What is the priority concept for the interdisciplinary care and treatment of a patient who is suspected
of having a stroke?
a. Pain
b. Cognition
c. Perfusion
d. Sensory perception - ANSWER: c. Perfusion
The preferred administration time for intravenous fibrinolytic therapy is generally within what time
frame of stroke symptom onset?
a. 30-60 mins
b. 3-4.5 hrs
c. 6-8 hrs
d. 24-30 hrs - ANSWER: b. 3-4.5 hrs
A pt who had a stroke several years ago continues to have the potential for aspiration. Which
intervention is best to delegate to UAP?
a. Monitor the pt for and notify the charge nurse of any occurrence of coughing, choking, or difficulty
breathing
b. Elevate the HOB and slowly feed small spoonfuls of pudding, pausing between each spoonful
c. Check for swallow reflex by placing index finger and thumb on the Adam's apple and palpating
during swallowing.
d. Give the pt a glass of water before feeding solid foods, and have oral suction ready at the bedside. -
ANSWER: b. Elevate the HOB and slowly feed small spoonfuls of pudding, pausing between each
spoonful
A pt is diagnosed with an ischemic stroke. UAP reports the pt's BP is 150/100. The pt's BP prior to the
stroke was normally around 120/80. What action does the nurse take first?
a. Immediately report BP to the provider bc there is a danger of rebleeding.
, b. Ask UAP to recheck the BP in the other extremity with a manual cuff.
c. Check the provider's orders to see is BP is within the acceptable parameters.
d. Document BP and continue to monitor bc an elevated BP is necessary for cerebral perfusion. -
ANSWER: c. Check the provider's orders to see is BP is within the acceptable parameters.
A pt with an ischemic stroke is placed on a cardiac monitor. Which cardiac dysrhythmia places the pt
at risk for emboli?
a. Sinus bradycardia
b. Atrial fibrillation
c. Sinus tachycardia
d. First-degree heart block - ANSWER: b. Atrial fibrillation
The nurse is caring for a pt receiving medication therapy to prevent recurrence of stroke. Which
medication is pharmacologically appropriate for this purpose?
a. Enteric-coated aspirin
b. Gabapentin
c. Alteplase
d. Acetaminophen - ANSWER: a. Enteric-coated aspirin
A pt sustained a stroke that affected the right hemisphere of the brain. The pt has visual spatial
deficits and deficits of proprioception. After assessing the safety of the pt's home, the home health
nurse identifies which environmental feature that represents a potential safety problem for this
patient?
a. The handrail that borders the bathtub is on the right-hand side
b. The pt's favorite chair faces the front door of the house.
c. The pt's bedside table is on the left-hand side of the bed.
d. Family has relocated the pt to a ground-floor bedroom. - ANSWER: a. The handrail that borders the
bathtub is on the right-hand side
The pt reports a sudden, severe headache with nausea and vomiting. He says, "This is the worst
headache of my life." What condition does the nurse suspect?
a. Brain tumor
b. Migraine headache
c. Cerebral aneurysm
d. Ischemic stroke - ANSWER: c. Cerebral aneurysm
A pt presents to the advanced stroke center with signs and symptoms of an ischemic stroke. What is
the priority factor when considering fibrinolytic therapy?
a. Age less than 80 years
b. Hx of stroke
c. Recent surgery
d. Time of onset of symptoms - ANSWER: d. Time of onset of symptoms
A pt received ateplase for the treatment of ischemic stroke. Following drug administration, the nurse
monitors for which adverse affect?
a. Severe headache and hypertension
b. Hypotension secondary to anaphylaxis
c. Respiratory depression and low O2 saturation
d. Elevated hematocrit or hemoglobin - ANSWER: a. Severe headache and hypertension
Ignatavicius, M. Linda Workman 9780323612425 Chapter 1-69
Complete Guide .
Which finding could help the health care team differentiate a TIA from a stroke?
a. Pt has a unilateral facial droop
b. Pt has slurred speech
c. Symptoms resolve in 30-60 mins
d. ECG is normal - ANSWER: c. Symptoms resolve in 30-60 mins
The nurse is preparing to discharge a pt with transient ischemic attacks. What topics does the nurse
include in discharge teaching? Select all that apply.
a. Reduction of high blood pressure
b. Drug teaching for aspirin or other antiplatelet drug
c. Lifestyle changes such as smoking cessation
d. Self-care for managing chronic conditions such as diabetes
e. Increased risk fro stroke and signs/symptoms
f. Benefits of taking vitamin supplements - ANSWER: a. Reduction of high blood pressure
b. Drug teaching for aspirin or other antiplatelet drug
c. Lifestyle changes such as smoking cessation
d. Self-care for managing chronic conditions such as diabetes
e. Increased risk fro stroke and signs/symptoms
The home health nurse is assessing a pt who had a stroke that affected the right hemisphere. What
would the nurse expect to observe?
a. Pt is overly anxious and cautious when asked to do a new task.
b. Pt is euphoric and smiling but disoriented to person, place and time.
c. Pt is depressed and expresses ongoing worries about the future
d. Pt has a flat affect but is able to answer most questions appropriately. - ANSWER: b. Pt is euphoric
and smiling but disoriented to person, place and time.
The nurse is assessing a pt who was brought to the ED for altered mental status. In the absence of
family members or witnesses to give a history, what does the nurse do to identify two conditions that
could mimic emergent neurologic conditions?
a. Check skin turgor and perform a bladder scan
b. Check blood glucose and oxygen saturation
c. Observe for jugular vein distention and pitting edema
d. Observe for jaundice and abdominal distention - ANSWER: b. Check blood glucose and oxygen
saturation
Following a left cerebral hemisphere stroke, the pt has expressive (Broca's) aphasia. Which
intervention is best to use when communicating with this patient?
a. Repeat the names of objects on a routine basis.
b. Face the pt and speak slowly and clearly
c. Obtain a whiteboard with an erasable marker
d. Use a picture board that displays objects and activities.. - ANSWER: d. Use a picture board that
displays objects and activities..
,The nurse is caring for a pt with right cerebral hemisphere damage. The pt demonstrates
disorientation to time and place and neglect of the left visual field, and he has poor depth perception.
Which task is best delegated to the UAP?
a. Move the pt's bed so that his affected side faces the door
b. Teach the pt to wash both sides of his face
c. Ensure a safe environment by removing clutter
d. Suggest to the family tat they bring familiar family photos - ANSWER: c. Ensure a safe environment
by removing clutter
A pt with a right cerebral hemisphere stroke may have safety issues related to which factor?
a. Poor impulse control
b. Alexia and agraphia
c. Loss of language and analytical skills
d. Slow and cautious behavior - ANSWER: a. Poor impulse control
A stroke pt is at risk for increased intracranial pressure and is receiving 2 L via nasal cannula. The
nurse is reviewing ABG results. Which value is of greatest concern for this patient?
a. pH of 7.32
b. PaCO2 of 60
c. PaO2 of 95
d. HCO3 of 28 - ANSWER: b. PaCO2 of 60
What is the priority concept for the interdisciplinary care and treatment of a patient who is suspected
of having a stroke?
a. Pain
b. Cognition
c. Perfusion
d. Sensory perception - ANSWER: c. Perfusion
The preferred administration time for intravenous fibrinolytic therapy is generally within what time
frame of stroke symptom onset?
a. 30-60 mins
b. 3-4.5 hrs
c. 6-8 hrs
d. 24-30 hrs - ANSWER: b. 3-4.5 hrs
A pt who had a stroke several years ago continues to have the potential for aspiration. Which
intervention is best to delegate to UAP?
a. Monitor the pt for and notify the charge nurse of any occurrence of coughing, choking, or difficulty
breathing
b. Elevate the HOB and slowly feed small spoonfuls of pudding, pausing between each spoonful
c. Check for swallow reflex by placing index finger and thumb on the Adam's apple and palpating
during swallowing.
d. Give the pt a glass of water before feeding solid foods, and have oral suction ready at the bedside. -
ANSWER: b. Elevate the HOB and slowly feed small spoonfuls of pudding, pausing between each
spoonful
A pt is diagnosed with an ischemic stroke. UAP reports the pt's BP is 150/100. The pt's BP prior to the
stroke was normally around 120/80. What action does the nurse take first?
a. Immediately report BP to the provider bc there is a danger of rebleeding.
, b. Ask UAP to recheck the BP in the other extremity with a manual cuff.
c. Check the provider's orders to see is BP is within the acceptable parameters.
d. Document BP and continue to monitor bc an elevated BP is necessary for cerebral perfusion. -
ANSWER: c. Check the provider's orders to see is BP is within the acceptable parameters.
A pt with an ischemic stroke is placed on a cardiac monitor. Which cardiac dysrhythmia places the pt
at risk for emboli?
a. Sinus bradycardia
b. Atrial fibrillation
c. Sinus tachycardia
d. First-degree heart block - ANSWER: b. Atrial fibrillation
The nurse is caring for a pt receiving medication therapy to prevent recurrence of stroke. Which
medication is pharmacologically appropriate for this purpose?
a. Enteric-coated aspirin
b. Gabapentin
c. Alteplase
d. Acetaminophen - ANSWER: a. Enteric-coated aspirin
A pt sustained a stroke that affected the right hemisphere of the brain. The pt has visual spatial
deficits and deficits of proprioception. After assessing the safety of the pt's home, the home health
nurse identifies which environmental feature that represents a potential safety problem for this
patient?
a. The handrail that borders the bathtub is on the right-hand side
b. The pt's favorite chair faces the front door of the house.
c. The pt's bedside table is on the left-hand side of the bed.
d. Family has relocated the pt to a ground-floor bedroom. - ANSWER: a. The handrail that borders the
bathtub is on the right-hand side
The pt reports a sudden, severe headache with nausea and vomiting. He says, "This is the worst
headache of my life." What condition does the nurse suspect?
a. Brain tumor
b. Migraine headache
c. Cerebral aneurysm
d. Ischemic stroke - ANSWER: c. Cerebral aneurysm
A pt presents to the advanced stroke center with signs and symptoms of an ischemic stroke. What is
the priority factor when considering fibrinolytic therapy?
a. Age less than 80 years
b. Hx of stroke
c. Recent surgery
d. Time of onset of symptoms - ANSWER: d. Time of onset of symptoms
A pt received ateplase for the treatment of ischemic stroke. Following drug administration, the nurse
monitors for which adverse affect?
a. Severe headache and hypertension
b. Hypotension secondary to anaphylaxis
c. Respiratory depression and low O2 saturation
d. Elevated hematocrit or hemoglobin - ANSWER: a. Severe headache and hypertension
