Nur 242 exam 4 Questions
and answers
The nurse is planning care for an immobilized client who had a stroke with
right-sided hemiparesis. Which activity would the nurse include in the plan
of care? - answer Assist the client to perform range-of-motion (ROM)
exercises every 1 to 2 hours
Which is the priority nursing action for a client admitted to the hospital in
a coma after having a stroke? - answer Maintain an open airway.
Which position would the nurse plan to use for the client who is having a
hypertensive crisis and evolving stroke? - answer Side-lying
Which nursing action is essential when a client experiences hemianopsia
as the result of a left ischemic stroke? - answer Place objects within the
visual field
Initially after a stroke, a client's pupils are equal and reactive to light.
Later, the nurse assesses that the right pupil is reacting more slowly than
the left and that the systolic blood pressure is rising. Which complication
would the nurse plan to address? - answer Increased intracranial pressure
The registered nurse (RN) is caring for a client who is currently
hospitalized for a stroke. Which professional management strategy will be
most effective for the RN to improve the safety and quality of client care?
- answer Delegation
The client taking intravenous coagulant medications for a bleeding
disorder suddenly develops an embolic stroke as a result of medication
overdose. Which actions by the hospital management does the Leapfrog
Group suggest? Select all that apply. One, some, or all responses may be
correct. - answer Apologize to the client and family.
Waive all costs directly related to the adverse effect.
,Report the adverse event to The Joint Commission.
Which action will the nurse complete when preparing a stroke client for
cerebral imaging with iodine-based contrast dye? - answer Ensure a recent
creatinine level has been assessed.
Which behaviors would the nurse include when teaching a family what to
expect from a client who experienced a stroke on the left side of the
brain? Select all that apply. One, some, or all responses may be correct. -
answer Slow performance and caution
Impaired speech/language aphasias
Awareness of deficits with depression and anxiety
When a client has difficulty swallowing after a stroke, which action by the
nurse would be most important in preventing pneumonia? - answer Having
suction available during meals
A client has had a recent brain attack (cerebrovascular accident/stroke).
Which preventative would the nurse anticipate will be prescribed daily to
avoid straining due to constipation? - answer Stool softener
Which intervention would the disaster management team nurse perform
for the survivors of an explosion who developed heat stroke? - answer
Apply ice packs on the client's scalp
Which level of care is the nurse providing when preparing to discharge a
client who is learning to walk again after a stroke to a rehabilitation
center? - answer tertiary care
Which action by the emergency department nurse is the priority for a
client with heat stroke? - answer Assess the airway and breathing
A client who sustains a stroke has a loss of proprioception and fine touch.
Which artery would the nurse suspect is damaged? - answer Anterior
cerebral
, A client has a brain attack (stroke) that involves the right cerebral cortex
and cranial nerves. Which areas of paralysis would the nurse expect to
find upon assessment? Select all that apply. One, some, or all responses
may be correct. - answer Left leg
Left arm
Left side of face
Initially after a stroke, the client's pupils are equal and reactive to light.
Four hours later, the nurse identifies that one pupil reacts more slowly
than the other and the client's systolic blood pressure is increasing. For
which condition would the nurse prepare to intervene? - answer Increased
intracranial pressure
The nurse observes dorsiflexion of the big toe and fanning of other toes
when the lateral side of a client's foot is stroked. Which finding would the
nurse document? - answer Exhibits a positive Babinski sign
The nurse is caring for a client who had a stroke and who has varying
moods ranging from anger to depression to concern about the aphasia,
hemiparesis, and the gavage feedings. Which behavior indicates the
client's acceptance of physical limitations? - answer Performs tube
feedings without assistance
A client has dysarthria after a stroke. Which goal would the nurse include
in the plan of care to address this problem? - answer Effective
communication
Which reflex is the nurse testing when using a dull object to stroke from
the lateral sole of a client's foot upward to the great toe? - answer
Babinski
A client admitted to the hospital with the diagnosis of a right-sided "brain
attack" (stroke) is right-handed. Which task will be most difficult for this
client? - answer Dressing every morning
The nurse assessed a client who experienced a recent brain attack
(stroke) and has a residual right-sided hemiplegia. Which rationale
and answers
The nurse is planning care for an immobilized client who had a stroke with
right-sided hemiparesis. Which activity would the nurse include in the plan
of care? - answer Assist the client to perform range-of-motion (ROM)
exercises every 1 to 2 hours
Which is the priority nursing action for a client admitted to the hospital in
a coma after having a stroke? - answer Maintain an open airway.
Which position would the nurse plan to use for the client who is having a
hypertensive crisis and evolving stroke? - answer Side-lying
Which nursing action is essential when a client experiences hemianopsia
as the result of a left ischemic stroke? - answer Place objects within the
visual field
Initially after a stroke, a client's pupils are equal and reactive to light.
Later, the nurse assesses that the right pupil is reacting more slowly than
the left and that the systolic blood pressure is rising. Which complication
would the nurse plan to address? - answer Increased intracranial pressure
The registered nurse (RN) is caring for a client who is currently
hospitalized for a stroke. Which professional management strategy will be
most effective for the RN to improve the safety and quality of client care?
- answer Delegation
The client taking intravenous coagulant medications for a bleeding
disorder suddenly develops an embolic stroke as a result of medication
overdose. Which actions by the hospital management does the Leapfrog
Group suggest? Select all that apply. One, some, or all responses may be
correct. - answer Apologize to the client and family.
Waive all costs directly related to the adverse effect.
,Report the adverse event to The Joint Commission.
Which action will the nurse complete when preparing a stroke client for
cerebral imaging with iodine-based contrast dye? - answer Ensure a recent
creatinine level has been assessed.
Which behaviors would the nurse include when teaching a family what to
expect from a client who experienced a stroke on the left side of the
brain? Select all that apply. One, some, or all responses may be correct. -
answer Slow performance and caution
Impaired speech/language aphasias
Awareness of deficits with depression and anxiety
When a client has difficulty swallowing after a stroke, which action by the
nurse would be most important in preventing pneumonia? - answer Having
suction available during meals
A client has had a recent brain attack (cerebrovascular accident/stroke).
Which preventative would the nurse anticipate will be prescribed daily to
avoid straining due to constipation? - answer Stool softener
Which intervention would the disaster management team nurse perform
for the survivors of an explosion who developed heat stroke? - answer
Apply ice packs on the client's scalp
Which level of care is the nurse providing when preparing to discharge a
client who is learning to walk again after a stroke to a rehabilitation
center? - answer tertiary care
Which action by the emergency department nurse is the priority for a
client with heat stroke? - answer Assess the airway and breathing
A client who sustains a stroke has a loss of proprioception and fine touch.
Which artery would the nurse suspect is damaged? - answer Anterior
cerebral
, A client has a brain attack (stroke) that involves the right cerebral cortex
and cranial nerves. Which areas of paralysis would the nurse expect to
find upon assessment? Select all that apply. One, some, or all responses
may be correct. - answer Left leg
Left arm
Left side of face
Initially after a stroke, the client's pupils are equal and reactive to light.
Four hours later, the nurse identifies that one pupil reacts more slowly
than the other and the client's systolic blood pressure is increasing. For
which condition would the nurse prepare to intervene? - answer Increased
intracranial pressure
The nurse observes dorsiflexion of the big toe and fanning of other toes
when the lateral side of a client's foot is stroked. Which finding would the
nurse document? - answer Exhibits a positive Babinski sign
The nurse is caring for a client who had a stroke and who has varying
moods ranging from anger to depression to concern about the aphasia,
hemiparesis, and the gavage feedings. Which behavior indicates the
client's acceptance of physical limitations? - answer Performs tube
feedings without assistance
A client has dysarthria after a stroke. Which goal would the nurse include
in the plan of care to address this problem? - answer Effective
communication
Which reflex is the nurse testing when using a dull object to stroke from
the lateral sole of a client's foot upward to the great toe? - answer
Babinski
A client admitted to the hospital with the diagnosis of a right-sided "brain
attack" (stroke) is right-handed. Which task will be most difficult for this
client? - answer Dressing every morning
The nurse assessed a client who experienced a recent brain attack
(stroke) and has a residual right-sided hemiplegia. Which rationale
