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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.
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A client who has experienced an initial transient ischemic attack (TIA) states: 'I'm glad it wasn't anything serious.' Which is the best nursing response to this statement?
- A. I sense that you are happy it was not a stroke.
- B. People who experience a TIA will develop a stroke.
- C. TIA symptoms are short-lived and resolve within 24 hours.
- D. TIA is a warning sign. Let's talk about lowering your risks.
Correct Answer: D
Rationale: TIA is a warning sign and can be used to empower clients to make life changes to lower the risks. Sensing the client is happy is a psychotherapeutic response but does not lead to teaching and learning for health promotion. TIAs can lead to a stroke for approximately one third of the clients but is not a definitive result and presents as a frightening statement without empowering change. TIA symptoms are short-lived, but this is a factual statement that does not provide additional information to the client.
A client is prescribed sumatriptan for the treatment of migraine headache. Which client statement would indicate a need for additional teaching from the nurse?
- A. I use this to prevent migraines.
- B. I take this when I get a headache.
- C. It constricts the blood vessels in my head.
- D. It alleviates my sensitivity to light and sound.
Correct Answer: A
Rationale: Sumatriptan is a serotonin receptor agonist that stimulates serotonin receptors in the brain and causes vasoconstriction of the cerebral arteries and reduce/eliminate headaches and other symptoms associated with migraines. Sumatriptan is used during an attack and is not indicated for preventative migraine therapy.
A client has just been diagnosed with a cerebral aneurysm. In planning discharge teaching for this client, what instructions should be delivered by the nurse to the client?
- A. Avoid heavy lifting.
- B. Avoid fiber in the diet.
- C. Take an antacid frequently.
- D. Take an herbal form of feverfew.
Correct Answer: A
Rationale: A client with an aneurysm should be advised to avoid heavy lifting, extreme emotional situations, or straining of stools because these activities increase intracranial pressure and thereby headaches and potential rupture of aneurysm. Avoidance of fiber may lead to constipation and straining with stools and would not be recommended. There would not be a recommendation for antacids or feverfew in the discharge teaching.
The nurse is providing teaching to a client who reports tension headaches. Which instruction would be beneficial to prevent onset of symptoms?
- A. Apply cool or warm cloth to head or eyes.
- B. Eliminate use of bright lights when working.
- C. Avoid certain foods.
- D. Perform stretching exercises and frequent position changes.
Correct Answer: D
Rationale: Tension headaches are often associated with prolonged tensed muscles. Application of cool or warm cloths and avoidance of bright lights may help to reduce the headache after occurrence. Avoiding certain foods may prevent migraine headaches but is not likely to prevent tension headaches.
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.