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
The nurse is assessing a client for a possible transient ischemic attack (TIA). Which of the following assessment findings suggests that the client is experiencing a TIA?
Correct Answer: A
Rationale: A client with a TIA may experience impaired muscle coordination or paralysis on one side. Respiratory distress and severe headache are not associated with TIA. Nausea and vomiting is not a usual symptom of TIA.
Question 2 of 5
A client is brought to the emergency department with symptoms of a cerebrovascular accident (CVA). The nurse would anticipate which diagnostic evaluation to be completed prior to initiation of treatment?
Correct Answer: C
Rationale: CT scan or MRI differentiates CVA from other disorders and can differentiate between ischemic or hemorrhagic strokes. PT level would be done if the client is receiving anticoagulant therapy. Chest x-ray may be performed if respiratory concerns are indicated. Lumbar puncture would be done if subarachnoid bleeding is suspected.
Question 3 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 4 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 5 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.