ATI LPN
Lewis's Medical Surgical Nursing in Canada, 5th Edition
Chapter 60 Questions
Question 1 of 5
The nurse is caring for a patient with a stroke who has progressive development of neurological deficits with increasing weakness and decreased level of consciousness (LOC). Which of the following nursing diagnoses has the highest priority for the patient?
Correct Answer: D
Rationale: Protection of the airway is the priority nursing care for a patient experiencing an acute stroke. The other diagnoses also are appropriate, but interventions to prevent aspiration are the priority at this time.
Question 2 of 5
The nurse is caring for a patient with sudden-onset right-sided weakness who has a CT scan and is diagnosed with an intracerebral hemorrhage. Which of the following information about the patient is most important to communicate to the health care provider?
Correct Answer: D
Rationale: The use of warfarin will have contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patient's care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated.
Question 3 of 5
The nurse is caring for a patient with a left-sided brain stroke who suddenly bursts into tears when family members visit. Which of the following actions should the nurse implement?
Correct Answer: D
Rationale: Patients who have left-sided brain stroke are prone to emotional outbursts, which are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient's outburst suggests that depression is not the major cause of the behaviour. The family should stay with the patient. The crying is not within the patient's control and asking the patient to stop will lead to embarrassment.
Question 4 of 5
The nurse is caring for a patient who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects. Which of the following actions should the nurse anticipate as treatment for this patient?
Correct Answer: C
Rationale: The patient's symptoms are consistent with transient ischemic attack (TI
A), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA.
Question 5 of 5
A patient is admitted to the hospital with dysphagia and right-sided weakness that resolves in a few hours. The nurse will anticipate teaching the patient about
Correct Answer: B
Rationale: Following a TIA, patients typically are started on medications such as Aspirin to inhibit platelet function and decrease stroke risk. tPA is used for acute ischemic stroke. Warfarin is usually used for patients with atrial fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage.