Question 1

Which intervention should the nurse include in a patient's plan of care to help preserve joint mobility in the acute phase of a CVA?

Accepted Answer

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. 
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. C

Question 2

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?

Accepted Answer

A)  Stroke in evolution with dysarthria 
B)  Lacunar stroke with fluent aphasia 
C)  Complete stroke with global aphasia 
D)  Stroke in evolution with dyspraxia 
A)  Stroke in evolution with dysarthria 
B)  Lacunar stroke with fluent aphasia 
C)  Complete stroke with global aphasia 
D)  Stroke in evolution with dyspraxia A

Question 3

Which patients with CVAs are considered candidates for treatment with tPA? (Select all that apply.)

Accepted Answer

A)  A 62-year-old construction worker who had a subdural hematoma 6 months earlier 
B)  A 58-year-old executive with a bleeding ulcer 
C)  A 44-year-old individual who had a seizure at the onset of a stroke 
D)  A 40-year-old individual who is taking warfarin (Coumadin)and has an INR of 2.5 
E)  A 19-year-old young adult with leukemia with a platelet count of 200,000 
A)  A 62-year-old construction worker who had a subdural hematoma 6 months earlier 
B)  A 58-year-old executive with a bleeding ulcer 
C)  A 44-year-old individual who had a seizure at the onset of a stroke 
D)  A 40-year-old individual who is taking warfarin (Coumadin)and has an INR of 2.5 
E)  A 19-year-old young adult with leukemia with a platelet count of 200,000 A, E

Question 4

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?

Accepted Answer

A)  Ischemic, embolic 
B)  Hemorrhagic, subarachnoid 
C)  Hemorrhagic, intracerebral 
D)  Ischemic, thrombotic 
A)  Ischemic, embolic 
B)  Hemorrhagic, subarachnoid 
C)  Hemorrhagic, intracerebral 
D)  Ischemic, thrombotic

Question 5

Which instruction is most helpful in teaching the family and patient who is in the rehabilitation phase after a CVA about altered sensation?

Accepted Answer

A)  Make frequent assessments for signs of pressure or injury. 
B)  Use the affected side in supporting the patient in ambulation and transfer to stimulate better sensation. 
C)  Apply ice packs to the affected limbs to encourage a return of sensation. 
D)  Apply a heating pad to the affected limbs to increase circulation. 
A)  Make frequent assessments for signs of pressure or injury. 
B)  Use the affected side in supporting the patient in ambulation and transfer to stimulate better sensation. 
C)  Apply ice packs to the affected limbs to encourage a return of sensation. 
D)  Apply a heating pad to the affected limbs to increase circulation.

Question 6

Which outcome criterion is the most appropriate for a patient with "Inadequate nutrition, related to dysphagia, with the goal of adequate intake of nutrients"?

Accepted Answer

A)  Offers a variety of food groups 
B)  Eats half of all meals offered 
C)  Maintains body weight of 150 to 155 lb 
D)  Eats all meals independently 
A)  Offers a variety of food groups 
B)  Eats half of all meals offered 
C)  Maintains body weight of 150 to 155 lb 
D)  Eats all meals independently

Question 7

A patient in the acute phase of an embolic CVA has an order for 400 units of heparin per hour IV.The heparin is in a solution of 5000 units/100 mL normal saline (NS).The nurse should set the electronic IV monitor at how many milliliters per hour?

Accepted Answer

A)  6 
B)  8 
C)  10 
D)  16 
A)  6 
B)  8 
C)  10 
D)  16

Question 8

Several days after a CVA, a patient's family asks a nurse if tissue plasminogen activator (tPA)is a drug therapy option now.The nurse's response is based on the knowledge that this drug must be used within how many hours after the onset of symptoms?

Accepted Answer

A)  3 
B)  5 
C)  10 
D)  24 
A)  3 
B)  5 
C)  10 
D)  24

Question 9

During the acute CVA phase, a risk for falls related to paralysis is present.Which intervention best protects the patient from injury?

Accepted Answer

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. 
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.

Question 10

Approximately 30% of individuals who experience a TIA have a stroke within ______ years.(Use numeric characters only.)

Accepted Answer

The answer of Approximately 30% of individuals who experience a...

Question 11

Which transitory symptoms might occur when a patient is diagnosed with a TIA? (Select all that apply.)

Accepted Answer

A)  Incontinence 
B)  Dysphagia 
C)  Ptosis 
D)  Tinnitus 
E)  Dysarthria 
A)  Incontinence 
B)  Dysphagia 
C)  Ptosis 
D)  Tinnitus 
E)  Dysarthria

Question 12

Which is the most effective intervention for best support of regular bowel elimination and the prevention of constipation?

Accepted Answer

A)  Limit fluid intake from 32 to 50 oz daily to compact the stool. 
B)  Administer small soapsuds enema every other day to cleanse the bowel. 
C)  Give stool softeners daily, establishing a consistent time to attempt elimination. 
D)  Administer a strong laxative on a daily basis to encourage evacuation. 
A)  Limit fluid intake from 32 to 50 oz daily to compact the stool. 
B)  Administer small soapsuds enema every other day to cleanse the bowel. 
C)  Give stool softeners daily, establishing a consistent time to attempt elimination. 
D)  Administer a strong laxative on a daily basis to encourage evacuation.

Question 13

A patient has weakness on the right side and impaired reasoning after having a cerebrovascular accident (CVA).What part of the brain is affected?

Accepted Answer

A)  Left hemisphere of the cerebrum 
B)  Right hemisphere of the cerebrum 
C)  Left cerebellum 
D)  Right cerebellum 
A)  Left hemisphere of the cerebrum 
B)  Right hemisphere of the cerebrum 
C)  Left cerebellum 
D)  Right cerebellum

Question 14

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?

Accepted Answer

A)  Patient's complaint of nausea 
B)  Blood pressure (BP)of 140/90 mm Hg 
C)  Patient's complaint of headache 
D)  Results of MRI 
A)  Patient's complaint of nausea 
B)  Blood pressure (BP)of 140/90 mm Hg 
C)  Patient's complaint of headache 
D)  Results of MRI

Question 15

A patient in the rehabilitation phase after a CVA accidentally knocks the adapted plate from the table and bursts into tears after failing to feed himself.What is the best response by the nurse?

Accepted Answer

A)  "Don't cry.You'll be mastering eating in no time." 
B)  "I don't believe crying will help.Let's try drinking from a special cup." 
C)  "Bless your heart! Let me get a new meal and feed you." 
D)  "Learning new skills is hard.Let's see what may have caused the trouble." 
A)  "Don't cry.You'll be mastering eating in no time." 
B)  "I don't believe crying will help.Let's try drinking from a special cup." 
C)  "Bless your heart! Let me get a new meal and feed you." 
D)  "Learning new skills is hard.Let's see what may have caused the trouble."

Question 16

A patient with homonymous hemianopsia is in the rehabilitation phase of a CVA.When arranging this patient's environment where should the nurse assure persons approaching and important items are visible and available?

Accepted Answer

A)  Unaffected side 
B)  Affected side 
C)  Direct front 
D)  Either side 
A)  Unaffected side 
B)  Affected side 
C)  Direct front 
D)  Either side

Question 17

Which assessment indicates a fluid volume excess in a patient in the acute phase of a CVA?

Accepted Answer

A)  Decreased BP 
B)  Weak pulse 
C)  Adventitious breath sounds 
D)  High urine-specific gravity 
A)  Decreased BP 
B)  Weak pulse 
C)  Adventitious breath sounds 
D)  High urine-specific gravity

Question 18

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?

Accepted Answer

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 
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

Question 19

What causes the 5% of strokes known to occur in persons younger than 45 years of age? (Select all that apply.)

Accepted Answer

A)  Drug abuse 
B)  Alcohol abuse 
C)  Birth control pills 
D)  Sickle cell anemia 
E)  Hemophilia 
A)  Drug abuse 
B)  Alcohol abuse 
C)  Birth control pills 
D)  Sickle cell anemia 
E)  Hemophilia

Question 20

Which posthospital option should the nurse encourage a patient to do when recovering from a CVA to provide the most comprehensive assistance?

Accepted Answer

A)  Transfer to a rehabilitation center. 
B)  Discharge to home with scheduled visits from home health care nurses. 
C)  Discharge to home with scheduled visits from a physical therapist. 
D)  Discharge to home with scheduled visits from an occupational therapist. 
A)  Transfer to a rehabilitation center. 
B)  Discharge to home with scheduled visits from home health care nurses. 
C)  Discharge to home with scheduled visits from a physical therapist. 
D)  Discharge to home with scheduled visits from an occupational therapist.

Exam 23: Cerebrovascular Accident

Which intervention should the nurse include in a patient's plan of care to help preserve joint mobility in the acute phase of a CVA?

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?

Which patients with CVAs are considered candidates for treatment with tPA? (Select all that apply.)

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?

Which instruction is most helpful in teaching the family and patient who is in the rehabilitation phase after a CVA about altered sensation?

Which outcome criterion is the most appropriate for a patient with "Inadequate nutrition, related to dysphagia, with the goal of adequate intake of nutrients"?

A patient in the acute phase of an embolic CVA has an order for 400 units of heparin per hour IV.The heparin is in a solution of 5000 units/100 mL normal saline (NS).The nurse should set the electronic IV monitor at how many milliliters per hour?

Several days after a CVA, a patient's family asks a nurse if tissue plasminogen activator (tPA)is a drug therapy option now.The nurse's response is based on the knowledge that this drug must be used within how many hours after the onset of symptoms?

During the acute CVA phase, a risk for falls related to paralysis is present.Which intervention best protects the patient from injury?

Approximately 30% of individuals who experience a TIA have a stroke within ______ years.(Use numeric characters only.)

Which transitory symptoms might occur when a patient is diagnosed with a TIA? (Select all that apply.)

Which is the most effective intervention for best support of regular bowel elimination and the prevention of constipation?

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 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 in the rehabilitation phase after a CVA accidentally knocks the adapted plate from the table and bursts into tears after failing to feed himself.What is the best response by the nurse?

A patient with homonymous hemianopsia is in the rehabilitation phase of a CVA.When arranging this patient's environment where should the nurse assure persons approaching and important items are visible and available?

Which assessment indicates a fluid volume excess in a patient in the acute phase of a CVA?

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?

What causes the 5% of strokes known to occur in persons younger than 45 years of age? (Select all that apply.)

Which posthospital option should the nurse encourage a patient to do when recovering from a CVA to provide the most comprehensive assistance?

Aspects of Medical-Surgical Nursing

Medical-Surgical Practice Settings

Medical-Surgical Patients: Individuals, Families, and Communities

Health, Illness, Stress, and Coping

Immunity, Inflammation, and Infection

Fluid, Electrolyte, and Acidbase Imbalance

The Patient With Cancer

Pain

Shock

The Older Adult Patient

Falls

Immobility

Delirium and Dementia

Incontinence

Nutrition

Intravenous Therapy

Surgery

The Patient With an Ostomy

Palliative and Hospice Care

Complementary and Alternative Therapies

Neurologic System Introduction

Neurologic Disorders

Spinal Cord Injury

Respiratory System Introduction

Upper Respiratory Disorders

Acute Lower Respiratory Tract Disorders

Chronic Lower Respiratory Tract Disorders

Hematologic System Introduction

Hematologic Disorders

Immunologic System Introduction

Immunologic Disorders

Cardiovascular System Introduction

Cardiac Disorders

Vascular Disorders

Hypertension

Digestive System Introduction

Upper Digestive Tract Disorders

Lower Digestive Tract Disorders

Liver, Gallbladder, and Pancreatic Disorders

Urologic System Introduction

Urologic Disorders

Musculoskeletal System Introduction

Connective Tissue Disorders

Fractures

Amputations

Endocrine System Introduction

Pituitary and Adrenal Disorders

Thyroid and Parathyroid Disorders

Diabetes and Hypoglycemia

Female Reproductive System Introduction

Female Reproductive Disorders

Male Reproductive System Introduction

Male Reproductive Disorders

Sexually Transmitted Infections

Integumentary System Introduction

Skin Disorders

Special Senses Introduction

Eye and Vision Disorders

Ear and Hearing Disorders