Test: Chapter 57: Stroke Lewis: Medical-Surgical Nursing, 10th Edition | Quizlet
Name:
2/19/23, 7:37 PM
Score:
20 Multiple choice questions
Term
1 of 20
Nurses in change-of-shift report are discussing the care of a patient with a stroke who
has progressively increasing weakness and decreasing level of consciousness. Which
patient problem do they determine has the highest priority for the patient?
Impaired physical mobility related to weakness
Disturbed sensory perception related to brain injury
Risk for impaired skin integrity related to immobility
Risk for aspiration related to inability to protect airway
Term
2 of 20
A 63-yr-old patient who began experiencing right arm and leg weakness is admitted to
the emergency department. In which order will the nurse implement these actions
included in the stroke protocol? (Put a comma and a space between each answer
choice [A, B, C, D].)
Obtain CT scan without contrast.
Infuse tissue plasminogen activator (tPA).
Administer oxygen to keep O2 saturation >95%.
Use National Institute of Health Stroke Scale to assess patient.
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Page 1 of 8
Test: Chapter 57: Stroke Lewis: Medical-Surgical Nursing, 10th Edition | Quizlet
2/19/23, 7:37 PM
Term
3 of 20
A patient with carotid atherosclerosis asks the nurse to describe a carotid
endarterectomy. Which response by the nurse is accurate?
"The obstructing plaque is surgically removed from inside an artery in the neck."
"The diseased portion of the artery in the brain is replaced with a synthetic graft."
"A wire is threaded through an artery in the leg to the clots in the carotid artery,
and the clots are removed."
"A catheter with a deflated balloon is positioned at the narrow area, and the
balloon is inflated to flatten the plaque."
Term
4 of 20
A left-handed patient with left-sided hemiplegia has difficulty feeding himself. Which
intervention should the nurse include in the plan of care?
Provide a wide variety of food choices.
Provide oral care before and after meals.
Assist the patient to eat with the right hand.
Teach the patient the "chin-tuck" technique.
Term
5 of 20
A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin
160 mg daily. When the nurse is administering medications, the patient says, "I don't
need the aspirin today. I don't have a fever." Which action should the nurse take?
Document that the aspirin was refused by the patient.
Tell the patient that the aspirin is used to prevent a fever.
Explain that the aspirin is ordered to decrease stroke risk.
Call the health care provider to clarify the medication order.
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Page 2 of 8
Test: Chapter 57: Stroke Lewis: Medical-Surgical Nursing, 10th Edition | Quizlet
2/19/23, 7:37 PM
Term
6 of 20
A patient with a stroke experiences facial drooping on the right side and right-sided
arm and leg paralysis. When admitting the patient, which clinical manifestation will the
nurse expect to find?
Impulsive behavior
Right-sided neglect
Hyperactive left-sided tendon reflexes
Difficulty comprehending instructions
Term
7 of 20
The nurse is caring for a patient who has been experiencing stroke symptoms for 60
minutes. Which action can the nurse delegate to a licensed practical/vocational nurse
(LPN/LVN)?
Assess the patient's gag and cough reflexes.
Determine when the stroke symptoms began.
Administer the prescribed short-acting insulin.
Infuse the prescribed IV metoprolol (Lopressor).
Term
8 of 20
A patient in the emergency department with sudden-onset right-sided weakness is
diagnosed with an intracerebral hemorrhage. Which information about the patient is
most important to communicate to the health care provider?
The patient's speech is difficult to understand.
The patient's blood pressure (BP) is 144/90 mm Hg.
The patient takes a diuretic because of a history of hypertension.
The patient has atrial fibrillation and takes warfarin (Coumadin).
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Page 3 of 8
Test: Chapter 57: Stroke Lewis: Medical-Surgical Nursing, 10th Edition | Quizlet
Term
2/19/23, 7:37 PM
9 of 20
A patient with left-sided weakness that started 60 minutes earlier is admitted to the
emergency department and diagnostic tests are ordered. Which test should be done
first?
Complete blood count (CBC)
Chest radiograph (chest x-ray)
Computed tomography (CT) scan
12-Lead electrocardiogram (ECG)
Term
10 of 20
Which information about the patient who has had a subarachnoid hemorrhage is most
important to communicate to the health care provider?
The patient complains of having a stiff neck.
The patient's blood pressure (BP) is 90/50 mm Hg.
The patient reports a severe and unrelenting headache.
The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).
Term
11 of 20
A patient arrives in the emergency department with hemiparesis and dysarthria that
started 2 hours previously, and health records show a history of several transient
ischemic attacks (TIAs). The nurse anticipates preparing the patient for
surgical endarterectomy.
transluminal angioplasty.
intravenous heparin drip administration.
tissue plasminogen activator (tPA) infusion.
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Page 4 of 8
Test: Chapter 57: Stroke Lewis: Medical-Surgical Nursing, 10th Edition | Quizlet
Term
2/19/23, 7:37 PM
12 of 20
Several weeks after a stroke, a 50-yr-old male patient has impaired awareness of
bladder fullness, resulting in urinary incontinence. Which nursing intervention should be
planned to begin an effective bladder training program?
Limit fluid intake to 1200 mL daily to reduce urine volume.
Assist the patient onto the bedside commode every 2 hours.
Perform intermittent catheterization after each voiding to check for residual urine.
Use an external "condom" catheter to protect the skin and prevent
embarrassment.
Term
13 of 20
After receiving change-of-shift report on the following four patients, which patient
should the nurse see first?
A 60-yr-old patient with right-sided weakness who has an infusion of tPA
prescribed
A 50-yr-old patient who has atrial fibrillation and a new order for warfarin
(Coumadin)
A 30-yr-old patient with a subarachnoid hemorrhage 2 days ago who has
nimodipine scheduled
A 40-yr-old patient who experienced a transient ischemic attack yesterday who
has a dose of aspirin due
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Page 5 of 8
Test: Chapter 57: Stroke Lewis: Medical-Surgical Nursing, 10th Edition | Quizlet
Term
2/19/23, 7:37 PM
14 of 20
During the change of shift report, a nurse is told that a patient has an occluded left
posterior cerebral artery. The nurse will anticipate that the patient may have
dysphasia.
confusion.
visual deficits.
poor judgment.
Term
15 of 20
Which stroke risk factor for a 48-yr-old male patient in the clinic is most important for
the nurse to address?
The patient is 25 lb above the ideal weight.
The patient drinks a glass of red wine with dinner daily.
The patient's usual blood pressure (BP) is 170/94 mm Hg.
The patient works at a desk and relaxes by watching television.
Term
16 of 20
The nurse is caring for a patient who has just returned after having left carotid artery
angioplasty and stenting. Which assessment information is of most concern to the
nurse?
The pulse rate is 102 beats/min.
The patient has difficulty speaking.
The blood pressure is 144/86 mm Hg.
There are fine crackles at the lung bases.
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Page 6 of 8
Test: Chapter 57: Stroke Lewis: Medical-Surgical Nursing, 10th Edition | Quizlet
Term
2/19/23, 7:37 PM
17 of 20
A female patient who had a stroke 24 hours ago has expressive aphasia. An appropriate
nursing intervention to help the patient communicate is to
ask questions that the patient can answer with "yes" or "no."
develop a list of words that the patient can read and practice reciting.
have the patient practice her facial and tongue exercises with a mirror.
prevent embarrassing the patient by answering for her if she does not respond.
Term
18 of 20
A patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which
intervention will the nurse include in the plan of care?
Apply intermittent pneumatic compression stockings.
Assist to dangle on edge of bed and assess for dizziness.
Encourage patient to cough and deep breathe every 4 hours.
Insert an oropharyngeal airway to prevent airway obstruction.
Term
19 of 20
A 70-yr-old female patient with left-sided hemiparesis arrives by ambulance to the
emergency department. Which action should the nurse take first?
Take the patient's blood pressure.
Check the respiratory rate and effort.
Assess the Glasgow Coma Scale score.
Send the patient for a computed tomography (CT) scan.
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Page 7 of 8
Test: Chapter 57: Stroke Lewis: Medical-Surgical Nursing, 10th Edition | Quizlet
Term
2/19/23, 7:37 PM
20 of 20
A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at
home that resolved after 2 hours. The nurse will anticipate teaching the patient about
tPA.
aspirin
warfarin (Coumadin)
nimodipine
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