Nokea
A family member comes to the clinic to talk to the nurse about a client who has had a stroke on the right side of the brain. The family member is concerned because of the deficits the client is exhibiting. The nurse knows that when a client experiences a stroke on the right side of the brain, common deficits include what? Select all that apply.
- A. Left-sided hemiplegia
- B. Tendency to distractibility
- C. Impairment of long-term memory
- D. Hyperaware of deficits
- E. Neglect of objects and people on the left side
Correct Answer: A,B,E
Rationale: Left-sided hemiplegia (stroke on right side of brain) may have the following neurologic deficits: spatial-perceptual defects; disregard for the deficits of the affected side require special safety considerations; tendency to distractibility; impulsive behavior, unaware of deficits; poor judgment; defects in left visual fields; misjudge distances; difficulty distinguishing upside-down and right-side up; impairment of short-term memory; and neglect left side of body, objects and people on left side.
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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 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 diagnosed with migraine headaches asks the nurse what to do to help control the headaches and minimize the number of attacks. What instructions should the nurse give this client?
- A. Identify and avoid factors that precipitate or intensify an attack.
- B. Keep a record of activities following an attack.
- C. When an attack occurs, stay in a brightly lit area.
- D. Write down any adverse drug effects.
Correct Answer: A
Rationale: The nurse includes the following instructions: Follow the indications and dosage regimen for medication and notify the physician of any adverse drug effects. Identify and avoid factors that precipitate or intensify an attack. Keep a food diary, which may help identify foods that trigger attacks. Keep a record of the attacks, including activities before the attack and environmental or emotional circumstances that appear to bring on the attack. Lie down in a darkened room and avoid noise and movement when an attack occurs whenever possible.
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.
An older adult client, who has fallen several times at home, is admitted for possible transient ischemic attack (TIA). Which assessment finding is most significant in determining care for this client?
- A. Becoming confused during the night
- B. Drooling from side of mouth
- C. Bruit heard over carotids
- D. Irregular heart rhythm
Correct Answer: B
Rationale: Facial droop and drooling from the side of the mouth can indicate progression of symptoms or evolving CVA. It is not unusual for older adult clients to become confused when placed in a new environment and would indicate a need for further assessment. Bruits over the carotids may indicate altered blood flow to the brain but may not be a new finding for this client. Irregular heart rate can be indicative of atrial fibrillation or other cardiac disorders.