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 providing teaching to a client who reports tension headaches. Which instruction would be beneficial to prevent onset of symptoms?
Correct Answer: D
Rationale: Tension headaches are often associated with prolonged tensed muscles. Application of cool or warm cloths and avoidance of bright lights may help to reduce the headache after occurrence. Avoiding certain foods may prevent migraine headaches but is not likely to prevent tension headaches.
Question 2 of 5
A client who has experienced an initial transient ischemic attack (TIA) states: 'I'm glad it wasn't anything serious.' Which is the best nursing response to this statement?
Correct Answer: D
Rationale: TIA is a warning sign and can be used to empower clients to make life changes to lower the risks. Sensing the client is happy is a psychotherapeutic response but does not lead to teaching and learning for health promotion. TIAs can lead to a stroke for approximately one third of the clients but is not a definitive result and presents as a frightening statement without empowering change. TIA symptoms are short-lived, but this is a factual statement that does not provide additional information to the client.
Question 3 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 4 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 5 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.