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The Client with a Cerebrovascular Accident
35. Regular oral hygiene is an essential intervention for the client who has had a cerebrovascular accident (CVA). Which of the following nursing measures is inappropriate when providing oral hygiene?
1. Placing the client on the back with a small pillow under the head.
A helpless client should be positioned on the side, not on the back, with the head on a small pillow.
2. Keeping portable suctioning equipment at the bedside.
3. Opening the client's mouth with a padded tongue blade.
4. Cleaning the client's mouth and teeth with a toothbrush.
A lateral position helps secretions escape from the throat and mouth, minimizing the risk of aspiration.
36. A client arrives in the emergency department with an ischemic CVA and receives tissue plasminogen activator (t-PA) administration. Which is the priority nursing assessment?
1. Current medications.
2. Complete physical and history.
A complete physical and history is not possible when a client is receiving emergency care.
3. Time of onset of current CVA.
Studies show that clients who receive recombinant t - PA treatment within 3 hours after the onset of a CVA have better outcomes. The time from the onset of stroke to t - PA treatment is a priority assessment.
4. Up coming surgical procedures.
Up coming surgical procedures may need to be delayed because of the administration of t - PA administration, which is a priority in the immediate treatment of the current CVA.
37. During the first 24 hours after thrombolytic treatment for an ischemic CVA, the primary goal is to control the client's
1. pulse.
2. respirations.
3. blood pressure.
Control of blood pressure is critical during the first 24 hours after treatment because an intracerebral hemorrhage is the major side effect of thrombolytic therapy.
Vital signs are monitored, and the blood pressure is maintained as identified by the physician and specific to the client's ischemic tissue needs and risk of bleeding from treatment.
4. temperature.
38. What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic CVA?
1. Cholesterol level.
The cholesterol level is not a priority assessment, although it may be an assessment to be addressed for long-term healthy lifestyle rehabilitation.
2. Pupil size and pupillary response.
It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves.
3. Bowel sounds.
Bowel sounds need to be assessed because an ileus or constipation can develop, but this is not a priority in the first 24 hours, when the primary concerns are cerebral hemorrhage and increased intracranial pressure.
4. Echocardiogram.
An echocardiogram is not needed for the client with a thrombotic CVA without heart problems.
39. What is a priority nursing intervention when suctioning an unconscious client to maintain cerebral perfusion?
1. Hyperoxygenate before and after suctioning.
It is a priority to hyperoxygenate the client before and after suctioning to prevent hypoxia and to maintain cerebral perfusion.
2. Administer analgesics.
Analgesics are administered to provide pain relief.
3. Provide oral hygiene.
Oral hygiene provides asepsis and comfort.
4. Administer diuretics.
Diuretics assist in reducing the intracranial pressure.
40. The nursing assessment of a client's functional status before and after a CVA is essential. Why is it so important?
1. The rehabilitation plan will be guided by it.
The primary reason for the nursing assessment of a client's functional status before and after a CVA is to guide the plan.
2. Functional status before the CVA will help predict outcomes.
The assessment does not help to predict how far the rehabilitation team can help the client to recover from the residual effects of the CVA, only what plans can help a client who has moved from one functional level to another. The nursing assessment of the client's functional status is not a motivating factor.
3. It will help the client recognize his physical limitations.
4. The client can be expected to regain much of his functioning.
41. Which of the following techniques does the nurse avoid when changing a client's position in bed if the client has hemiparalysis? .
1. Rolling the client onto her side.
Rolling the client is an acceptable method to use when changing positions as long as the client is maintained in anatomically neutral positions and her limbs are properly supported.
2. Sliding the client to move her up in bed.
Sliding a client on a sheet causes friction and is to be avoided.
Friction injures skin and predisposes to pressure ulcer formation.
3. Lifting the client when moving her up in bed.
The client may be lifted as long as the nurse has assistance and uses proper body mechanics to avoid injury to himself or herself or the client.
4. Having the client help lift herself off the bed using a trapeze.
Having the client help lift herself off the bed with a trapeze is an acceptable means to move a client without causing friction burns or skin breakdown.
42. Which nursing intervention has been found to be the most effective means of preventing plantar flexion in a client who has had a CVA with residual paralysis?
1. Place the client's feet against a firm footboard.
2. Reposition the client every 2 hours.
Footboards stimulate spasms and are not routinely recommended.
3. Have the client wear ankle-high tennis shoes at intervals throughout the day.
The use of ankle-high tennis shoes has been found to be most effective in preventing plantar flexion (foot drop) because they add support to the foot and keep it in the correct anatomic position.
4. Massage the client's feet and ankles regularly.
Regular repositioning and range-of-motion exercises are important interventions, but the client's foot needs to be left in correct anatomic position to prevent overextension of the muscle and tendon of the foot.
43. The nurse is planning the care of a hemiplegic client to prevent joint deformities of the arm. What position would be inappropriate?
1. Placing a pillow in the axilla so that the arm is away from the body.
Placing a pillow in the axilla so that the arm is away from the body keeps the arm abducted and prevents skin from touching skin, which leads to skin breakdown.
2. Placing a pillow under the slightly flexed arm so that the hand is higher than the elbow.
Placing a pillow under the slightly flexed arm so that the hand is higher than the elbow prevents edema.
3. Positioning the hands in a slightly pronated position.
When voluntary muscle control is lost, the flexor muscles, which are stronger, exert control over the extensor muscles. Folding the arms over the chest allows the flexor muscles to flex and exert control over the already weaker extensor muscles.
It is better to extend the arms of the client to allow the extensor muscles to exert control over the flexor muscles and prevent contractures.
4. Positioning a roll in the hand so that the fingers are barely flexed.
Positioning a roll in the hand so that the fingers are barely flexed prevents the flexor muscles from overtaking the extensors.
44. For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication?
1. Speaking loudly.
2. Using a picture board.
Expressive aphasia is a condition in which the client understands what is heard or written but cannot say what he or she wants to say. A communication or picture board helps the client communicate with others in that the client can point to objects or activities that he or she desires.
3. Writing directions so client can read them.
4. Speaking in short sentences.
45. The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which of the following strategies is inappropriate?
1. Maintaining an upright position.
Maintaining an upright position while eating is appropriate because it minimizes the risk of aspiration.
2. Restricting the diet to liquids until swallowing improves.
A client with dysphagia (difficulty swallowing) frequently has the most difficulty ingesting thin liquids, which are easily aspirated. Liquids should be thickened to avoid aspiration.
3. Introducing foods on the unaffected side of the mouth.
Introducing foods on the unaffected side allows the client to have better control over the food bolus.
4. Keeping distractions to a minimum.
The client should concentrate on chewing and swallowing; therefore, distractions should be avoided.
46. Which food-related behaviors would the nurse observe in a client who has had a CVA that has left him with homonymous hemianopia?
1. Increased preference for foods high in salt.
2. Eating food on only half of the plate.
Homonymous hemianopia is blindness in half of the visual field; therefore, the client would see only half of his plate. Eating only the food on half of the plate results from an inability to coordinate visual images and spatial relationships. There may be an increased preference for foods high in salt after a CVA, but this would not be related to homonymous hemianopia.
3. Forgetting the names of foods.
Forgetting the names of foods would be aphasia, which involves a cerebral cortex lesion.
4. Inability to swallow liquids.
Being unable to swallow liquids is dysphagia, which involves motor pathways of cranial nerves IX and X, including the lower brain stem.
47. The nurse is teaching the client about ways to adapt to a visual disability. Which does the nurse identify as the primary safety precaution to use?
1. Wear a patch over one eye.
2. Place personal items on the sighted side.
3. Lie in bed with the unaffected side toward the door.
4. Turn the head from side to side when walking.
To expand the visual field, the partially sighted client should be taught to turn the head from side to side when walking. Neglecting to do so may result in accidents. This technique helps maximize the use of remaining sight.
48. A client is experiencing mood swings after a CVA and often has episodes of tearfulness that are distressing to the family. Which is the best technique for the nurse to instruct family members to try when the client experiences a crying episode?
1. Sit quietly with the client until the episode is over.
2. Ignore the behavior.
Ignoring the behavior will not affect the mood swing or the crying and may increase the client's sense of isolation.
3. Attempt to divert the client's attention.
A client who has brain damage may be emotionally labile and may cry or laugh for no explainable reason. Crying episodes are best dealt with by attempting to divert the client's attention.
4. Tell the client that this behavior is unacceptable.
Telling the client to stop is inappropriate.
49. The client who has had a CVA with residual physical handicaps becomes discouraged by his physical appearance. What attitude is best for the nurse to display to help the client overcome his negative self-concept?
1. Helpfulness and sympathy.
2. Concern and charity.
3. Directives and firmness.
4. Encouragement and patience.
When offering emotional support to a client who is discouraged and has a negative self-concept because of physical handicaps, the nurse should display encouragement and patience. The client should be praised when he shows progress in his efforts to overcome handicaps. An attitude of helpfulness and sympathy allows the client to assume a role of someone not ordinary, someone who is not like others. Regardless of the handicap, the client still feels the same on the inside and has the same innate needs for his growth and developmental age group. An attitude of concern and charity tends to make the client feel like a "charity case" or like someone who is given something free because of his "condition." The client feels unequal to his peers or unable to fulfill the role relationships that were obtained before the CVA. An attitude of directives and firmness is inappropriate because it implies that the client can do better if he just tries harder and leaves no room for softness in the approach to overcoming a negative self-concept.
50. When communicating with a client who has aphasia, which of the following nursing interventions is inappropriate?
1. Present one thought at a time.
Presenting one thought at a time decreases stimuli that may distract the client, as does speaking in a normal volume and tone.
2. Encourage the client not to write messages.
The nurse should encourage the client to write messages or use alternative forms of communication to avoid frustration.
3. Speak with normal volume.
4. Make use of gestures.
The nurse should ask the client to "show me" and should encourage the use of gestures to assist in getting the message across with minimal frustration and exhaustion for the client.
51. What is the expected outcome of thrombolytic drug therapy for CVA?
1. Increased vascular permeability.
2. Vasoconstriction.
3. Dissolved emboli.
Thrombolytic enzyme agents are used for clients with a thrombotic CVA to dissolve emboli, thus reestablishing cerebral perfusion. They do not increase vascular permeability, cause vasoconstriction, or prevent further hemorrhage.
4. Prevention of hemorrhage.
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