Chapter 30
1. Which of the following assessment data alerts the nurse to the fact that the client is at risk
for an embolic stroke?
1. History of atrial fibrillation
2. Blood sugar of 110 mg
3. BP 108/68
4. Right partial lobectomy 6 months ago
Answer: History of atrial fibrillation
Rationale:
Embolisms from cardiac sources are referred to as cardiogenic embolisms. The most common
cause is atrial fibrillation, which accounts for almost 20% of all ischemic (embolic) strokes.
Hypotension, a normal blood glucose level, and a partial lobectomy are not risk factors for
embolic strokes.
2. After being informed that their father has experienced a stroke that has affected a portion of
his cerebrum, the client’s family asks the nurse, “What affect will aphasia have on his life?”
The nurse responds by stating:
1. “The way he communicates with you will change.”
2. “You’ll have to speak very loudly when you talk.”
3. “He will likely become depressed until he adjusts to the dysfunction.”
4. “Perhaps you should learn about the different options for speech therapy.”
Answer: “The way he communicates with you will change.”
Rationale:
Aphasia is the term used to denote problems with verbal communication. The Broca’s area in
the cerebrum regulates verbal expression—the ability to say words. Speaking loudly is more
related to a hearing problem; doing so will have little impact on the client’s ability to
communicate verbally. Depression may occur but it does not address the client’s verbal
communication issues. Speech therapy may be an option for rehabilitation but it does not
provide an answer to the question asked.
3. A nurse is preparing an educational program focusing on various types of strokes. Which
of the following should be included in a discussion of ischemic strokes?
Select all that apply.
1. Atherosclerotic thrombotic
2. Cardioembolic
3. Lacunar
4. Subarachnoid hemorrhagic
5. Intracerebral hemorrhagic
Answer: 1. Atherosclerotic thrombotic
2. Cardioembolic
3. Lacunar
Rationale:
Atherosclerotic thrombotic. Atherosclerotic thrombotic strokes are considered ischemic in
nature because they restrict or obstruct blood flow to a portion of the brain, resulting in
cellular death. Cardioembolic. Cardioembolic strokes are considered ischemic in nature
because they restrict or obstruct blood flow to a portion of the brain, resulting in cellular
death. Lacunar. Lacunar strokes are considered ischemic in nature because they restrict or
obstruct blood flow to a portion of the brain, resulting in cellular death. Subarachnoid
hemorrhagic. Subarachnoid hemorrhagic strokes are a result of a severe blood loss from the
vascular system of the brain. Intracerebral hemorrhagic. Intracerebral hemorrhagic strokes are
a result of a severe blood loss from the vascular system of the brain.
4. A poststroke client is going home on oral warfarin (Coumadin). During discharge teaching,
which statement by the client would reflect an understanding of the effects of this
medication?
1. “I don’t like green vegetables, so not eating them will be a pleasure.”
2. “I will stop taking this medicine if I notice any bruising.”
3. “It will be OK for me to eat anything, as long as it is low-fat.”
4. “I’ll check my blood pressure frequently while taking this medication.”
Answer: “I don’t like green vegetables, so not eating them will be a pleasure.”
Rationale:
Warfarin is a vitamin K antagonist. Green, leafy vegetables contain vitamin K, and will
therefore interfere with the therapeutic effects of the drug. Bruising is a common side effect,
and the drug should not be stopped unless by prescriber order. Low-fat foods do not interfere
with warfarin therapy. Warfarin is not prescribed to affect the blood pressure.
5. When the nurse reinforces education regarding the risks of bypass procedures for a client
who has experienced an ischemic stroke, which of the following is included?
Select all that apply.
1. Hemorrhage
2. Infection
3. Thrombotic stroke
4. Unstable blood pressure
5. Renal failure
Answer: 1. Hemorrhage
2. Infection
3. Thrombotic stroke
4. Unstable blood pressure
Rationale:
Hemorrhage. Bypass procedures carry significant risk to the patient, including hemorrhage of
the vessel. Infection. All surgical procedures, including bypass procedures, carry risks of
infection and alteration in wound healing. Thrombotic stroke. Bypass procedures carry
significant risk to the patient, such as stroke due to clot in the graft or stroke due to a variety
of other factors. Unstable blood pressure. Bypass procedures carry significant risk to the
patient, such as blood pressure instability. Renal failure. Renal failure is not considered a
classic risk for these procedures.
6. A 27-year-old male arrives at the emergency room reporting a sudden severe-onset
headache. He denied any recent head trauma and added that he was, “just partying with
friends” before the headache began. Diagnostic studies confirm he is experiencing an
intracerebral hemorrhage. The nurse recognizes that the greatest risk factor for such a stroke
in his age group is:
1. Amphetamine abuse.
2. Hypertension.
3. Cigarette smoking.
4. Undiagnosed diabetes mellitus.
Answer: Amphetamine abuse.
Rationale:
Sudden onset of symptoms, especially a severe headache, is a common sign of intracerebral
hemorrhage. When this type of stroke is seen in a young adult, and trauma is ruled out as the
cause, drug use should be suspected, specifically cocaine or amphetamines. Cigarette
smoking, hypertension, and diabetes mellitus are risk factors for ischemic strokes.
7. An emergency department nurse caring for a client who has been diagnosed with an
ischemic stroke that preceded a fall anticipates the need to initially prepare the client for:
1. Administration of t-PA (tissue plasminogen activator).
2. A CT scan (computerized tomography).
3. Full-body x-ray series.
4. Craniotomy.
Answer: Administration of t-PA (tissue plasminogen activator).
Rationale:
The administration of t-PA does not affect the infarcted, necrotic core, but may revitalize the
penumbra and limit the extent of damage caused by ischemic stroke, thus minimizing the
effects of the stroke. A CT scan is a diagnostic tool to confirm the diagnosis of an ischemic
stroke. An x-ray series is directed toward the identification of possible bone damage resulting
from the fall but would not take priority over t-PA administration. A craniotomy evacuates a
hematoma to relieve mass effect resulting from a hemorrhagic stroke.
8. A client is admitted with signs of a stroke (CVA). On admission, vital signs were: blood
pressure 128/70, pulse 68, and respirations 20, pupils equal and reactive, client awake and
responding to verbal stimuli. Two hours later the client is not awake but is easily aroused, has
a blood pressure of 140/70, pulse 52, respirations 18, and the left pupil is now slower than the
right pupil in reacting to light. These findings are a result of:
1. Increased intracranial pressure.
2. Impending brain death.
3. Reperfusion injury.
4. Normal stabilization poststroke.
Answer: Increased intracranial pressure.
Rationale:
Rising systolic blood pressure, falling pulse, and a pupil that has become sluggish suggest
increasing intracranial pressure (IICP) and require notification of the health care provider.
The most current assessment findings indicate that the client’s condition is becoming more
unstable. Brain death is diagnosed by lack of brain waves and inability to maintain vital
function. Reperfusion injury results in further injury to already damaged tissue that is
compromised, and may be seen most often with thrombolytic therapy.
9. The nursing caring for a client who experienced an ischemic stroke 8 hours ago recognizes
that the medication being administered for the purpose of preventing further obstruction of
vascular cerebral blood flow is:
Select all that apply.
1. Intravenous heparin.
2. Subcutaneous low-molecular-weight heparin.
3. Intravenous mannitol.
4. Intravenous dopamine.
5. Subcutaneous insulin.
Answer: 1. Intravenous heparin.
2. Subcutaneous low-molecular-weight heparin.
Rationale:
Intravenous heparin. Anticoagulation with IV infusion of heparin for several days during the
acute care management of a patient with ischemic stroke is common. Subcutaneous lowmolecular-weight heparin. Some institutions use low-molecular-weight heparin (LMWH)
subcutaneously instead of intravenous heparin. Intravenous mannitol. Intravenous mannitol is
utilized to reduce intracranial pressure and brain mass. Intravenous dopamine. Intravenous
dopamine is a vasopressor directed at stabilizing blood pressure. Subcutaneous insulin.
Subcutaneous insulin may be used to manage hyperglycemia resulting from ineffective
utilization of glucose.
10. A client is being treated in the emergency department for a possible aneurysmal
subarachnoid hemorrhage (SAH). The nurse recognizes which of the following assessment
data as risk factors for such a neurological emergency?
Select all that apply
1. Takes an alpha blocker daily
2. Age 58
3. History of rheumatoid arthritis
4. Smoker, ½ pack a day
5. Diesel truck mechanic
Answer: 1. Takes an alpha blocker daily
2. Age 58
3. History of rheumatoid arthritis
4. Smoker, ½ pack a day
Rationale:
Takes an alpha-blocker daily. Hypertension (may be treated with a daily dose of an alphablocker) is considered a risk factor for a cerebral aneurysm. Age 58. Age greater than 40 is
considered a risk factor for a cerebral aneurysm. History of rheumatoid arthritis. A history of
a connective tissue disorder (e.g., rheumatoid arthritis) is considered a risk factor for a
cerebral aneurysm. Smoker, ½ pack a day. Smoking is considered a risk factor for a cerebral
aneurysm. Diesel truck mechanic. There is no known increased risk related to work as a
diesel truck mechanic.
11. A diagnosis of inappropriate antidiuretic hormone syndrome is made for a client who
recently experienced a subarachnoid hemorrhage (SAH) and is hyponatremic. The nurse
recognizes the importance of:
Select all that apply.
1. Administering oral salt supplements.
2. Strictly monitoring intake and output.
3. Monitoring hypertonic IV fluid therapy.
4. Securing a serum sodium level every 6 hours.
5. Restricting the client’s fluids to 200 ml daily.
Answer: 1. Administering oral salt supplements.
2. Strictly monitoring intake and output.
3. Monitoring hypertonic IV fluid therapy.
4. Securing a serum sodium level every 6 hours.
Rationale:
Administering oral salt supplements. Generally, the treatment for hyponatremia in SAH is
hypertonic saline with oral salt supplements, if possible. Strictly monitoring intake and
output. It is important for the patient’s fluid intake and output to be carefully monitored.
Monitoring hypertonic IV fluid therapy. It is important for the patient’s fluid intake and
output to be carefully monitored because poor management of hypertonic fluid intake can
result in cardiac overload problems. Securing a serum sodium level every 6 hours. It is very
important for the patient’s serum sodium levels to be monitored frequently, every 6 hours if
the patient is receiving hypertonic saline. Restricting the client’s fluids to 200 ml daily. Fluid
restriction in this setting is absolutely contraindicated.
12. A client is given the option of either endovascular coiling or neurosurgical clipping in
response to experiencing an intracranial aneurysm. The nurse understands that the benefits of
endovascular coiling include:
Select all that apply.
1. The probability of being disability-free at 1 year is high.
2. Postprocedure hospital stay is significantly shorter.
3. The procedure requires less surgical expertise.
4. Most aneurysms are suitable for the procedure.
5. The financial expense is marginally less.
Answer: 1. The probability of being disability-free at 1 year is high.
2. Postprocedure hospital stay is significantly shorter.
Rationale:
The probability of being disability-free at 1 year is high. The outcome for survival free of
disability at 1 year is significantly higher with endovascular coiling. Postprocedure hospital
stay is significantly shorter. There is a decreased hospital length of stay associated with the
procedure. The procedure requires less surgical expertise. Treatment would occur at a
hospital with neurosurgeons specially trained in the procedure. Most aneurysms are suitable
for the procedure. The choice of treatment should be based on the angiographic
demonstration of the aneurysm. The financial expense is marginally less. The expense of
endovascular coiling is actually higher than that of surgical clipping, but the expense is more
than compensated for by the decreased hospital length of stay and the patient’s earlier return
to work and normal activities of daily living (ADLs)
13. A client is being treated for an aneurysmal subarachnoid hemorrhage (SAH) that occurred
10 days ago. The nurse recognizes that the client is at risk for decreased cerebral blood flow
and is especially concerned when the client:
Select all that apply.
1. Has a temperature of 101˚ F.
2. Reports a stiff neck.
3. Seems unable to verbalize his needs.
4. Has unequal but reactive pupils.
5. Has difficulty starting his flow of urine.
Answer: 1. Has a temperature of 101˚ F.
2. Reports a stiff neck.
3. Seems unable to verbalize his needs.
Rationale:
Has a temperature of 101˚ F. The peak incidence of vasospasm is from 3 to 14 days from the
incidence of SAH, although it may occur up to 21 days after the bleed occurs. Signs of
vasospasm include fever. Reports a stiff neck. The peak incidence of vasospasm is from 3 to
14 days from the incidence of SAH, although it may occur up to 21 days after the bleed
occurs. Signs of vasospasm include neck stiffness. Seems unable to verbalize his needs. The
peak incidence of vasospasm is from 3 to 14 days from the incidence of SAH, although it
may occur up to 21 days after the bleed occurs. Signs of vasospasm include aphasia. Has
unequal but reactive pupils. Signs of vasospasm do not include abnormal pupil size or
reaction. Has difficulty starting his flow of urine. Signs of vasospasm do not include urinary
hesitation.
14. The nurse is caring for a client who is being treated for cerebral vasospasm with a
medical treatment referred to as triple-H therapy. Which of the following assessment data
confirm that the treatment is currently effective?
Select all that apply.
1. BP 170/96
2. Hematocrit 34%
3. Mean arterial pressure (MAP) 110 mmHg
4. Intercranial pressure (ICP) 10 mmHg
5. Urine output 40 ml/hr
Answer: 1. BP 170/96
2. Hematocrit 34%
3. Mean arterial pressure (MAP) 110 mmHg
4. Intercranial pressure (ICP) 10 mmHg
Rationale:
BP 170/96. Triple-H therapy consists of hypertension, hemodilution, and hypervolemia. The
goal of triple-H therapy is to increase cerebral perfusion pressure and CBF, therefore
reducing the risk for further neurological deficits. Systolic blood pressure should be kept at
no less than 160 mmHg. Hematocrit 34%. Triple-H therapy consists of hypertension,
hemodilution, and hypervolemia. The goal of triple-H therapy is to increase cerebral
perfusion pressure and CBF, therefore reducing the risk for further neurological deficits.
Hematocrit should be between 32% and 35% to reflect good cerebral perfusion. Mean arterial
pressure (MAP) 110 mmHg. Triple-H therapy consists of hypertension, hemodilution, and
hypervolemia. The goal of triple-H therapy is to increase cerebral perfusion pressure and
CBF, therefore reducing the risk for further neurological deficits. Mean arterial pressure
(MAP) should be between 60 and 150 mmHg. Intercranial pressure (ICP) 10 mmHg. TripleH therapy consists of hypertension, hemodilution, and hypervolemia. The goal of triple-H
therapy is to increase cerebral perfusion pressure and CBF, therefore reducing the risk for
further neurological deficits. Systolic blood pressure should be kept at no less than 160
mmHg. Urine output 40 ml/hr. Urine output is not considered an assessment value for
monitoring triple-H therapy.
15. The nurse is caring for a client who is at risk for developing cerebral vasospasm. The
nurse recognizes which of the following as an inappropriate order for such a client?
1. Discontinue IV fluids when tolerating fluids.
2. Hold client’s carvedilol (Coreg).
3. Monitor blood pressure hourly.
4. Monitor serum electrolytes daily.
Answer: Discontinue IV fluids when tolerating fluids.
Rationale:
Patients with subarachnoid hemorrhage are at significant risk for vasospasm. Do not
discontinue IV fluids even if the patient has adequate oral intake. Monitor blood pressure at
least hourly. Do not administer antihypertensive medications without parameters for
administration. Monitoring serum electrolytes, especially sodium, is appropriate.
Test Bank for Timby's Introductory Medical-Surgical Nursing
Loretta A Donnelly-Moreno, Brigitte Moseley
9781975172237, 9781975172268
