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 with a cerebrovascular accident (CVA) is having difficulty with eating food on the plate. Which is the best priority nursing action to be taken?
Correct Answer: A
Rationale: The nurse should perform a vision field assessment to evaluate the client for hemianopia. This finding could indicate damage to the visual area of the brain as a result of evolving CVA. Repositioning the tray and assisting with feeding would not be the best nursing action until new finding has been evaluated. Hemianopia can be associated with a CVA but, when presenting as a new finding, should be evaluated and reported immediately.
Question 2 of 5
Which nursing assessment finding is most indicative of a hemorrhagic stroke?
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.
Question 3 of 5
A diagnostic test has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include thickened liquids. Which of the following is the priority nursing diagnosis for this client?
Correct Answer: C
Rationale: Impaired Swallowing was evident on the video fluoroscopy. Aspiration, Malnutrition, and Decreased Fluid Volume Risk can occur but are not the primary diagnosis at this point in time.
Question 4 of 5
A client is admitted for evaluation of cerebral aneurysm. Which assessment finding is of greatest importance in prioritizing nursing care to this client?
Correct Answer: C
Rationale: Nausea needs to be controlled to prevent vomiting, which can greatly increase the intracranial pressure and subsequently rupture the aneurysm. Complaint of headache for the past month is significant to the evaluation at hand but should be addressed after the nausea has been controlled. Having no bowel movement since yesterday is not significant; although, every effort should be made to prevent constipation. Frequent voiding is expected especially with the use of osmotic diuretics.
Question 5 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.