The nurse is planning care for a client who displays confusion secondary to a brain attack (stroke). Which approaches by the nurse would be helpful in assisting this client? Select all that apply.

1.Providing sensory cues

2.Giving simple, clear directions

3.Providing a stable environment

4.Keeping family pictures at the bedside

5.Encouraging family members to visit at the same time

1.Providing sensory cues

2.Giving simple, clear directions

3.Providing a stable environment

4.Keeping family pictures at the bedside

The nurse is reviewing the medical records of a client admitted to the nursing unit with a diagnosis of a thrombotic brain attack (stroke). The nurse would expect to note that which is documented in the assessment data section of the record?

1.Sudden loss of consciousness occurred.

2.Signs and symptoms occurred suddenly.

3The client experienced paresthesias a few days before admission to the hospital.

4The client complained of a severe headache, which was followed by sudden onset of paralysis.

3The client experienced paresthesias a few days before admission to the hospital.

The nurse assesses a client who is diagnosed with a stroke (brain attack). On assessment, the client is unable to understand the nurse's commands. Which condition would the nurse document?

1.Occipital lobe impairment

2.Damage to the auditory association areas

3.Frontal lobe and optic nerve tracts damage

4.Difficulty with concept formation and abstraction areas

2.Damage to the auditory association areas

The nurse is performing an assessment on a client with a diagnosis of thrombotic stroke (brain attack). Which assessment question would elicit data specific to this type of stroke?

1. "Have you had any headaches in the past few days?"

2"Have you recently been having difficulty with seeing at nighttime?"

3"Have you had any sudden episodes of passing out in the past few days?"

4"Have you had any numbness or tingling or paralysis-type feelings in any of your extremities recently?"

4"Have you had any numbness or tingling or paralysis-type feelings in any of your extremities recently?"

The nurse is creating a plan of care for a client with dysphagia following a stroke (brain attack). Which would the nurse include in the plan? Select all that apply.

1.Thicken liquids.

2.Assist the client with eating.

3.Assess for the presence of a swallow reflex.

4.Place the food on the affected side of the mouth.

5.Provide ample time for the client to chew and swallow.

1.Thicken liquids.

2.Assist the client with eating.

3.Assess for the presence of a swallow reflex.

5.Provide ample time for the client to chew and swallow.

The nurse is creating a plan of care for a client with a stroke (brain attack) who has right homonymous hemianopsia. Which would the nurse include in the plan of care for the client?

1.Place an eye patch on the left eye.

2Place personal articles on the client's right side.

3.Approach the client from the right field of vision.

4.Instruct the client to turn the head to scan the right visual field.

4.Instruct the client to turn the head to scan the right visual field.

The nurse is caring for a client with a diagnosis of right (nondominant) hemispheric stroke. The nurse notes that the client is alert and oriented to time and place. On the basis of these assessment findings, the nurse would make which interpretation?

1.Had a very mild stroke

2.Most likely suffered a transient ischemic attack

3.May have difficulty with language abilities only

4.Is likely to have perceptual and spatial disabilities

4.Is likely to have perceptual and spatial disabilities

The nurse is creating a plan of care for a client with a stroke (brain attack) who has global aphasia. The nurse would incorporate communication strategies into the plan of care because of which expected characteristic of the client's speech?

1.Intact

2.Rambling

3.Characterized by literal paraphasia

4.Associated with poor comprehension

4.Associated with poor comprehension

The nurse is creating a plan of care for a client with a diagnosis of stroke (brain attack) with anosognosia. To meet the needs of the client with this deficit, the nurse would include activities that will achieve which outcome?

1.Encourage communication.

2.Provide a consistent daily routine.

3.Promote adequate bowel elimination.

4.Increase the client's awareness of the affected side.

4.Increase the client's awareness of the affected side.

At 8:00 a.m., a client who has had a stroke (brain attack) was awake and alert with vital signs of temperature 98° F (37.2° C) orally, pulse 80 beats/min, respirations 18 breaths/min, and blood pressure 138/80 mm Hg. At noon, the client is confused and only responsive to tactile stimuli, and vital signs are temperature 99° F (36.7° C) orally, pulse 62 beats/min, respirations 20 breaths/min, and blood pressure 166/72 mm Hg. The nurse would take which action first?

1.Reorient the client.

2.Retake the vital signs.

3.Call the primary health care provider (PHCP).

4.Administer an antihypertensive PRN (as needed).

3.Call the primary health care provider (PHCP).

At the end of the work shift, the nurse is reviewing the respiratory status of a client admitted with a stroke (brain attack) earlier in the day. The nurse determines that the client's airway is patent if which data are identified?

1.Respiratory rate 24 breaths/min, oxygen saturation 94%, breath sounds clear

2.Respiratory rate 18 breaths/min, oxygen saturation 98%, breath sounds clear

3.Respiratory rate 16 breaths/min, oxygen saturation 85%, wheezes bilaterally

4.Respiratory rate 20 breaths/min, oxygen saturation 92%, diminished breath sounds in lung bases

2.Respiratory rate 18 breaths/min, oxygen saturation 98%, breath sounds clear

A client who had a stroke (brain attack) has right-sided hemianopsia. What would the nurse plan to do to help the client adapt to this problem?

1.Teach the client to scan the environment.

2Place all objects within the left visual field.

3Place all objects within the right visual field.

4Ensure that the family brings the client's eyeglasses to hospital.

1.Teach the client to scan the environment.

Which assessment finding would the nurse expect to note in the client hospitalized with a diagnosis of brain attack (stroke) who has difficulty chewing food?

1.Dysfunction of vagus nerve (cranial nerve X)

2.Dysfunction of trigeminal nerve (cranial nerve V)

3.Dysfunction of hypoglossal nerve (cranial nerve XII)

4.Dysfunction of spinal accessory nerve (cranial nerve XI)

2.Dysfunction of trigeminal nerve (cranial nerve V)

The nurse is caring for a client who had a stroke and is experiencing a neurological deficit involving the hippocampus. On assessment of the client, which signs and symptoms would most likely be noted?

1.Disoriented to client, place, and time

2.Affect flat, with periods of emotional lability

3.Cannot recall what was eaten for breakfast today

4.Unable to add and subtract; does not know who is president

3.Cannot recall what was eaten for breakfast today

A client has sustained damage to Wernicke's area from a stroke (brain attack). On assessment of the client, which sign or symptom would be noted?

1.Difficulty speaking

2.Problem with understanding language

3.Difficulty controlling voluntary motor activity

4.Problem with articulating events from the remote past

2.Problem with understanding language

A client who had a brain attack (stroke) has suffered damage to Broca's area of the brain. Which priority assessment would the nurse perform?

1.Speech

2.Hearing

3.Balance

4.Level of consciousness

1.Speech

A client who suffered a brain attack (stroke) is prepared for discharge from the hospital. The primary health care provider has prescribed range-of-motion (ROM) exercises for the client's right side. What action would the nurse include in the client's plan of care?

1.Implement ROM exercises to the point of pain for the client.

2.Consider the use of active, passive, or active-assisted exercises in the home.

3.Develop a schedule of ROM exercises every 2 hours while awake even if the client is fatigued

4.Encourage the client to be dependent on the home care nurse to complete the exercise program.

2.Consider the use of active, passive, or active-assisted exercises in the home.

The nurse is assessing the function of cranial nerve XII in a client who sustained a brain attack (stroke). To assess function of this nerve, which action would the nurse ask the client to perform?

1.Extend the arms.

2.Extend the tongue.

3.Turn the head toward the nurse's arm.

4.Focus the eyes on the object held by the nurse.

2.Extend the tongue.

The nurse is caring for a client who has just been admitted to the hospital with a diagnosis of a hemorrhagic stroke. The nurse would place the client in which position?

1.Prone

2.Supine

3.Semi-Fowler's with the hip and the neck flexed

4.Head of the bed elevated 30 degrees with the head in midline position

4.Head of the bed elevated 30 degrees with the head in midline position

The nurse is caring for a client who is at risk for increased intracranial pressure (ICP) after a stroke. Which activities performed by the nurse will assist with preventing increases in ICP? Select all that apply.

1.Clustering nursing activities

2.Hyperoxygenating before suctioning

3.Maintaining 20-degree flexion of the knees

4.Maintaining the head and neck in midline position

5.Maintaining the head of the bed (HOB) at 30 degrees elevation

2.Hyperoxygenating before suctioning

4.Maintaining the head and neck in midline position

5.Maintaining the head of the bed (HOB) at 30 degrees elevation

The nurse is trying to communicate with a client who had a stroke and has aphasia. Which actions by the nurse would be most helpful to the client? Select all that apply.

1.Speaking to the client at a slower rate

2.Allowing plenty of time for the client to respond

3.Completing the sentences that the client cannot finish

4.Looking directly at the client during attempts at speech

5.Shouting words if it seems as though the client has difficulty understanding

1.Speaking to the client at a slower rate

2.Allowing plenty of time for the client to respond

4.Looking directly at the client during attempts at speech

The nurse is caring for a client who is in the chronic phase of stroke (brain attack) and has a right-sided hemiparesis. The nurse identifies that the client is unable to feed self. Which is the appropriate nursing intervention?

1.Assist the client to eat with the left hand to build strength.

2.Provide a pureed diet that is easy for the client to swallow.

3.Inform the client that a feeding tube will be placed if progress is not made.

4.Provide a variety of foods on the meal tray to stimulate the client's appetite.

1.Assist the client to eat with the left hand to build strength.

A client is newly admitted to the hospital with a diagnosis of stroke (brain attack) manifested by complete hemiplegia. Which item in the medical history of the client would the nurse be most concerned about?

1.Glaucoma

2.Emphysema

3.Hypertension

4.Diabetes mellitus

2.Emphysema

A client who has had a stroke (brain attack) has residual dysphagia. When a diet prescription is initiated, the nurse would take which actions? Select all that apply.

1.Giving the client thin liquids

2.Thickening liquids to the consistency of oatmeal

3.Placing food on the unaffected side of the mouth

4.Allowing plenty of time for chewing and swallowing

5.Leaving the client alone so that the client will gain independence by feeding self

2.Thickening liquids to the consistency of oatmeal

3.Placing food on the unaffected side of the mouth

4.Allowing plenty of time for chewing and swallowing

The nurse is caring for a client who was admitted for a stroke (brain attack) of the temporal lobe. Which clinical manifestations would the nurse expect to note in the client?

1.The client will be unable to recall past events.

2.The client will have difficulty understanding language.

3The client will have difficulty moving one side of the body.

4The client will demonstrate difficulty in articulating words.

2.The client will have difficulty understanding language.

The nurse is performing a neurological assessment on a client who had a stroke (brain attack). The nurse checks for proprioception using which assessment technique?

1.Tapping the Achilles tendon using the reflex hammer

2.Gently pricking the client's skin on the dorsum of the foot in two places

3.Firmly stroking the lateral sole of the foot and under the toes with a blunt instrument

4.Holding the sides of the client's great toe and, while moving it, asking what position it is in

4.Holding the sides of the client's great toe and, while moving it, asking what position it is in

A home care nurse is assessing a client's activities of daily living (ADLs) after a stroke. What would the nurse include in the client's focused assessment?

1.Ability to drive a car

2.The normal everyday routine in the home

3.Ability to do light or heavy housework and to pay bills

4.Self-care needs such as toileting, feeding, and ambulating

4.Self-care needs such as toileting, feeding, and ambulating

The nurse is assisting in the care of a group of clients on the nursing unit. When considering the effects of each medical diagnosis, the nurse determines that which client has the least risk for developing third spacing of fluid?

1.Client with a major burn

2.Client with an ischemic stroke

3.Client with Laënnec's cirrhosis

4.Client with chronic kidney disease

2.Client with an ischemic stroke

The home care nurse is visiting a client who is recovering at home after suffering a stroke 2 weeks ago. The client's spouse states that the client has difficulty feeding themself and difficulty with swallowing food and fluids. Which would be the initial nursing action?

1.Observe the client feeding themself.

2.Observe the spouse feeding the client.

3Arrange for a home health aide to assist at mealtimes.

4Instruct the spouse in the use of a feeding syringe to feed the client.

1.Observe the client feeding themself.

The nurse is caring for a client with impaired mobility that occurred as the result of a stroke. The client has right-sided arm and leg weakness. Which assistive device would the nurse suggest that the client use to provide the best stability for ambulating?

1.Walker

2.Crutches

3.Quad cane

4.Single straight-legged cane

3.Quad cane

The nurse is instructing a client who had a stroke and has weakness on one side how to ambulate with the use of a cane. Which instruction would the nurse provide to the client?

1.Hold the cane on the affected (weak) side.

2.Hold the cane on the unaffected (strong) side.

3.Move the cane forward first along with the unaffected (strong) leg.

4.Move the cane and the unaffected (strong) leg down first when going down stairs.

2.Hold the cane on the unaffected (strong) side.

A client with right leg hemiplegia from a stroke has a problem with mobility. The nurse determines a need for reinforcement of teaching the client and the client's family if the nurse observes which action being done by the family?

1.Applying a premolded splint

2.Active range of motion to the affected leg

3.Passive range of motion to the affected leg

4.Encouraging the client to stand unassisted on the leg

4.Encouraging the client to stand unassisted on the leg

The nurse is providing instructions to an assistive personnel (AP) who is assigned to care for a client who had a brain attack (stroke) and is experiencing hemiparesis of the right arm and leg. Where would the nurse instruct the AP to place personal articles for morning care?

1.Within the client's reach on the left side

2.Within the client's reach on the right side

3.Just out of the client's reach on the left side

4.Just out of the client's reach on the right side

1.Within the client's reach on the left side

A client who had a brain attack (stroke) has an impairment of cranial nerve II. To maintain safety in the home, the nurse would plan to teach the spouse to implement which measure?

1.Speak to the client in a loud voice.

2.Serve food that is not too hot or too cold.

3.Keep traveled paths in the home free of clutter.

4.Lower the temperature setting of the hot water heater.

3.Keep traveled paths in the home free of clutter.

The nurse is teaching a client who had a stroke how to use a walker for ambulation. Which level of prevention is the nurse implementing?

1.Basic level.

2Primary level

3.Secondary level.

4.Tertiary level

4.Tertiary level

A nursing student is caring for a client with a stroke who is experiencing unilateral neglect. The nurse would intervene if the student plans to use which strategy to help the client adapt to this deficit?

1.Telling the client to scan the environment

2.Placing the bedside articles on the affected side

3.Approaching the client from the unaffected side

4.Moving the commode and chair to the affected side

3.Approaching the client from the unaffected side

A client is scheduled to take ticlopidine. The nurse plans to take which action before implementing this medication therapy?

1.Take the client's blood pressure.

2.Obtain a prothrombin time (PT).

3.Take the client's apical heart rate.

4.Review the results of the complete blood cell (CBC) count.

4.Review the results of the complete blood cell (CBC) count.

A neurologist prescribed ticlopidine to the client with thrombotic stroke. The nurse provides instructions to the client and spouse regarding the medication. Which statement made by the client indicates that education was effective?

1."I'll take the medicine with meals."

2"If I do not feel well, I should skip the medication."

3"I won't have another stroke if I take this medicine faithfully."

4"If I have any gastrointestinal side effects, I should call the neurologist."

1."I'll take the medicine with meals."

The nurse provides instructions to a client who has a prescription for ticlopidine. Which statement made by the client indicates a need for further teaching?

1."I'll take my medicine with meals."

2"Blood work will be done every 2 weeks for the first 3 months."

3"I would not stop the medication without talking to my doctor first."

4"Food will affect the medication, so I need to take the medication on an empty stomach."

4"Food will affect the medication, so I need to take the medication on an empty stomach."

The nurse is reviewing the primary health care provider's (PHCP's) prescriptions for a client recently admitted to the hospital and notes that the PHCP has prescribed ticlopidine therapy. Which finding on the client's record would indicate a need to contact the PHCP before initiating the medication prescription?

1.Neutropenia

2.Client history of stroke

3.Client history of hypertension

4.Complaints of gastrointestinal disturbances

1.Neutropenia

The nurse has completed client teaching on the use of thrombolytic medications in acute ischemic stroke. The nurse determines that the educational session was effective if the client states that thrombolytics are used for what purpose?

1.To dissolve clots

2.To prevent ischemia

3.To prevent bleeding

4.To decrease anxiety

1.To dissolve clots

A client is taking ticlopidine hydrochloride. The nurse would tell the client to avoid which substance while taking this medication?

1.Vitamin C

2.Vitamin D

3.Acetaminophen

4.Acetylsalicylic acid

4.Acetylsalicylic acid

The nurse is teaching a client with right-sided weakness related to a stroke about how to properly ambulate with a cane. Which client action would indicate a need for further teaching?

1. The client holds the cane on the right side of the body.

2.The client moves the weaker leg toward the cane first.

3.The client holds the cane 6 inches laterally from the foot.

4.The client keeps two points of support on the floor at all times.

1. The client holds the cane on the right side of the body.

The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply.

1.The client is aphasic.

2.The client has weakness on the right side of the body.

3.The client has complete bilateral paralysis of the arms and legs.

4.The client has weakness on the right side of the face and tongue.

5.The client has lost the ability to move the right arm but is able to walk independently.

6.The client has lost the ability to ambulate independently but is able to feed and bathe self without assistance.

1.The client is aphasic.

2.The client has weakness on the right side of the body.

4.The client has weakness on the right side of the face and tongue.

The nurse has instructed the family of a client with a stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client?

1."We need to discourage wearing eyeglasses."

2."We need to place objects in the impaired field of vision."

3."We need to approach from the impaired field of vision."

4."We need to encourage head turning to scan the lost visual field."

4."We need to encourage head turning to scan the lost visual field."

The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully?

1.Gets angry with family if they interrupt a task

2.Experiences bouts of depression and irritability

3.Has difficulty with using modified feeding utensils

4.Consistently uses adaptive equipment in dressing self

4.Consistently uses adaptive equipment in dressing self