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A client has experienced a transient ischemic attack (TIA) and presents with carotid bruits. Which is the priority action to be taken by the nurse, following a bilateral carotid endarterectomy?
- A. Encourage deep breathing and coughing.
- B. Observe for facial swelling.
- C. Anticipate need for endotracheal intubation.
- D. Resume antilipemic drugs.
Correct Answer: C
Rationale: Surgical approach to the neck area can result in swelling and blockage of the airway. This is especially significant with bilateral carotid endarterectomy. The nurse must be observant and prepared for immediate intubation if the airway becomes obstructed. Encouraging deep breathing and coughing is not significant because general anesthesia is not routine. Resuming drugs for hyperlipidemia is not a priority in the acute postoperative period.
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A client presents to the walk-in clinic complaining of a migraine. The client is prescribed an antileptic. What should the nurse suggest to the client?
- A. Avoid crowds.
- B. Take drugs only after meals at night.
- C. Avoid caffeine and alcohol.
- D. Use caution while driving or performing hazardous activities.
Correct Answer: D
Rationale: A client who is prescribed an antileptic needs to exercise caution while driving and avoid performing hazardous activities. A client taking non-steroidal anti-inflammatory drugs should be advised against taking caffeine and alcohol. The client need not take the drug only at night after meals or be instructed to avoid crowds.
A client is brought into the emergency department with a diagnosis of ruptured cerebral aneurysm. Which assessment data provides the most important information in preparing for the nursing care of this client?
- A. Blood pressure 180/98 mm Hg
- B. Alert and oriented times three
- C. Grade V on the Hunt-Hess Scale
- D. Complaint of severe splitting headache
Correct Answer: C
Rationale: The Hunt-Hess Scale is used for grading a client with a cerebral aneurysm and provides the most accurate assessment as listed. An elevated blood pressure is anticipated with a cerebral aneurysm. Being alert and oriented provides little assessment value without additional neurologic data. Complaint of severe headache is subjective and not as significant as results from using the Hunt-Hess Scale.
A client with a cerebrovascular accident (CVA) is having difficulty with eating food on the plate. Which is the best priority nursing action to be taken?
- A. Perform a vision field assessment.
- B. Reposition the tray and plate.
- C. Assist the client with feeding.
- D. Know this is a normal finding for CVA.
Correct Answer: A
Rationale: The nurse should perform a vision field assessment to evaluate the client for hemianopia. This finding could indicate damage to the visual area of the brain as a result of evolving CVA. Repositioning the tray and assisting with feeding would not be the best nursing action until new finding has been evaluated. Hemianopia can be associated with a CVA but, when presenting as a new finding, should be evaluated and reported immediately.
The nurse is caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke does the nurse know this client has?
- A. Ischemic
- B. Hemorrhagic
- C. Right-sided
- D. Left-sided
Correct Answer: A
Rationale: Ischemic strokes occur when a thrombus or embolus obstructs an artery carrying blood to the brain; about 80% of strokes are the ischemic variety. The other options are incorrect.
A client has been found unresponsive at home for an undetermined period of time. A cerebrovascular accident (CVA) is suspected, and the family is demanding a clot buster be used to restore functioning. The nurse knows that successful use of tissue plasminogen activator (TPA) in a client with CVA requires which factor(s) to be true? Select all that apply.
- A. Symptoms no longer evolving
- B. Presence of an ischemic stroke
- C. Used concurrently with heparin therapy
- D. Administered intramuscularly for faster response
- E. Administered within 3 hours of onset of symptoms
- F. Administered for hemorrhagic strokes
Correct Answer: B,E
Rationale: TPA is a thrombolytic agent that can limit neurologic${{content}} neurologic deficits if given IV within 3 hours of onset of an ischemic CVA. Waiting for symptoms to stabilize (no longer evolving) may take days and would not be appropriate for the use of TPA. TPA is not used in conjunction with other anticoagulants and would never be used to treat a hemorrhagic stroke (promotes more bleeding).