ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 38 : Caring for Clients With Cerebrovascular Disorders Questions
Question 1 of 5
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?
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.
Question 2 of 5
A client is prescribed sumatriptan for the treatment of migraine headache. Which client statement would indicate a need for additional teaching from the nurse?
Correct Answer: A
Rationale: Sumatriptan is a serotonin receptor agonist that stimulates serotonin receptors in the brain and causes vasoconstriction of the cerebral arteries and reduce/eliminate headaches and other symptoms associated with migraines. Sumatriptan is used during an attack and is not indicated for preventative migraine therapy.
Question 3 of 5
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?
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.
Question 4 of 5
A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which finding?
Correct Answer: B
Rationale: When the infarct is on the left side of the brain, the symptoms are likely to be on the right, and the speech is more likely to be involved. If the MRI reveals an infarct, TIA is no longer the diagnosis. There is not enough information to determine if the stroke is still evolving or is complete.
Question 5 of 5
A client has experienced a transient ischemic attack (TIA) and presents with carotid bruits. Which is the priority action to be taken by the nurse, following a bilateral carotid endarterectomy?
Correct Answer: C
Rationale: Surgical approach to the neck area can result in swelling and blockage of the airway. This is especially significant with bilateral carotid endarterectomy. The nurse must be observant and prepared for immediate intubation if the airway becomes obstructed. Encouraging deep breathing and coughing is not significant because general anesthesia is not routine. Resuming drugs for hyperlipidemia is not a priority in the acute postoperative period.