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Which nursing assessment finding is most indicative of a hemorrhagic stroke?
- A. Client history of atrial fibrillation
- B. Sudden onset of breathing alterations
- C. Symptoms evolving over 24 to 48 hours
- D. Client history of hyperlipidemia
Correct Answer: B
Rationale: Hemorrhagic strokes are less common than ischemic strokes and usually present with sudden onset and have the most impact on breathing, blood pressure, and heart rate. Client history of atrial fibrillation and hyperlipidemia are most significant with ischemic strokes caused by embolus or plaque. Ischemic strokes tend to evolve over 24 to 48 hours until symptoms complete.
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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.
A family member brings a 76-year-old client to the clinic, stating that the client has had two transient ischemic attacks (TIAs) in the past week. The health care provider orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option(s) does the nurse expect the health care provider to offer this client to increase blood flow to the brain? Select all that apply.
- A. Balloon angioplasty of the carotid artery followed by stent placement
- B. Removal of the carotid artery
- C. Percutaneous transluminal coronary artery angioplasty
- D. Carotid endarterectomy
- E. Administration of tissue plasminogen activator
Correct Answer: A,D
Rationale: If narrowing of the carotid artery by atherosclerotic plaques is the cause of the TIAs, a carotid endarterectomy (surgical removal of atherosclerotic plaque) could be performed. A balloon angioplasty of the carotid artery, a procedure similar to a percutaneous transluminal coronary artery angioplasty, may be performed alternatively to dilate the carotid artery and increase blood flow to the brain, followed by stent placement. The other options are not options to increase blood flow through the carotid artery to the brain.
While making initial rounds after coming on shift, the nurse finds a client thrashing about in bed complaining of a severe headache. The client tells the nurse the pain is behind the right eye, which is red and tearing. What type of headache would the nurse suspect this client of having?
- A. Migraine
- B. Tension
- C. Cluster
- D. Sinus
Correct Answer: C
Rationale: A person with a cluster headache has pain on one side of the head, usually behind the eye, accompanied by nasal congestion, rhinorrhea (watery discharge from the nose), and tearing and redness of the eye. The pain is so severe that the person is not likely to lie still; instead, the person may pace or thrash about. The symptoms in the scenario do not describe the other types of headaches listed.
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 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.