1. The nurse is obtaining a health history for a client admitted to the hospital after experiencing a brain attack. Which disorder does the nurse identify as a predisposing factor for an embolic stroke?

a.            Seizures

b.            Psychotropic drug use

c.             Atrial fibrillation

d.            Cerebral aneurysm

ANS: C

Clients with a history of hypertension, heart disease, atrial fibrillation, diabetes, obesity, and hypercoagulopathy are at risk for embolic stroke. The other disorders are not risk factors for an embolic stroke.

DIF: Cognitive Level: Knowledge/Remembering REF: p. 1012

TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC: Integrated Process: Nursing Process (Assessment)

2. A client with aphasia presents to the emergency department with a suspected brain attack. Which clinical manifestation leads the nurse to suspect that this client has had a thrombotic stroke?

a.            Two episodes of speech difficulties in the last month

b.            Sudden loss of motor coordination

c.             A grand mal seizure 2 months ago

d.            Chest pain and nuchal rigidity

ANS: A

Thrombotic stroke is characterized by a gradual onset of symptoms that often are preceded by transient ischemic attacks (TIAs), causing a focal neurologic dysfunction. Two episodes of speech difficulties would correlate with TIAs. The other manifestations are not related to a thrombotic stroke.

DIF: Cognitive Level: Comprehension/Understanding REF: Table 47-1, p. 1006

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC: Integrated Process: Nursing Process (Analysis)

3. The nurse is caring for an 80-year-old client who presented to the emergency department in a coma. Which question does the nurse ask the client’s family to help determine whether the coma is related to a brain attack?

a.            “How many hours does your mother usually sleep at night?”

b.            “Did your mother complain recently of weakness in her lower extremities?”

c.             “Is any history of seizures known among your mother’s immediate family?”

d.            “Does your mother drink any alcohol or take any medications?”

ANS: D

Conditions such as drug or alcohol intoxication, as well as hypoxemia and metabolic disturbances, can cause profound changes in level of consciousness (LOC) when accompanied by a brain attack. Alcohol abuse and medication toxicity can be especially problematic in older adults. The other manifestations are related to a stroke but would not increase the client’s risk of coma.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

4. The nurse is assessing a client who had a stroke in the right cerebral hemisphere. Which neurologic deficit does the nurse assess for in this client?

a.            Impaired proprioception

b.            Aphasia

c.             Agraphia

d.            Impaired olfaction

ANS: A

A stroke to the right cerebral hemisphere causes impaired visual and spatial awareness. The client may present with impaired proprioception and may be disoriented as to time and place. The right cerebral hemisphere does not control speech, smell, or the client’s ability to write.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

5. A client who had a stroke combs her hair only on the right side of her head and washes only the right side of her face. How does the nurse interpret these actions?

a.            Poor left-sided motor control

b.            Paralysis or contractures on the right side

c.             Limited visual perception of the left fields

d.            Unawareness of the existence of her left side

ANS: D

Clients who have experienced a right hemisphere stroke often have neglect syndrome, in which they are unaware of the existence of the paralyzed side, or the left side. This injury would not have an effect on the client’s sight. This is not related to poor motor control or paralysis.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1011

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Analysis)

6. The nurse notes that the left arm of a client who has experienced a brain attack is in a contracted, fixed position. Which complication of this position does the nurse monitor for in this client?

a.            Shoulder subluxation

b.            Flaccid hemiparesis

c.             Pathologic fracture

d.            Neglect syndrome

ANS: A

Hypertonia causing contracture or flaccidity can predispose the client to subluxation of the shoulder. Contractures are stiff and immobile—not flaccid. Contractures are not caused by fractures or neglect syndrome.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Analysis)

7. The nurse is caring for a client who has experienced a stroke. Which nursing intervention for nutrition does the nurse implement to prevent complications from cranial nerve IX impairment?

a.            Turn the client’s plate around halfway through the meal.

b.            Place the client in high Fowler’s position.

c.             Order a clear liquid diet for the client.

d.            Verbalize the placement of food on the client’s plate.

ANS: B

Cranial nerve IX, the glossopharyngeal nerve, controls the gag reflex. Clients with impairment of this nerve are at great risk for aspiration. The client should be in high Fowler’s position and should drink thickened liquids if swallowing difficulties are present. The client would not have vision problems. Turning the plate around would not prevent a complication, nor would limiting the client’s diet to clear liquids.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

8. A client who had a brain attack was admitted to the intensive care unit yesterday. The nurse observes that the client is becoming lethargic and is unable to articulate words when speaking. What does the nurse do next?

a.            Check the client’s blood pressure and apical heart rate.

b.            Elevate the back rest to 30 degrees and notify the health care provider.

c.             Place the client in a supine position with a flat back rest, and observe.

d.            Assess the client’s white blood cell count and differential.

ANS: B

The client is experiencing signs of increased intracranial pressure (ICP). Raising the head of the bed would help decrease ICP. The health care provider should then be notified immediately so that other interventions to reduce ICP can be instituted. Assessing vital signs and white blood cell count is not the priority at this time.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)