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STROKE- NCLEX Detailed Questions And Expert Answers
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STROKE- NCLEX Detailed Questions And Expert Answers
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STROKE- NCLEX Detailed Questions And ExpertAnswers
The nurse is caring for a patient with a history of transient ischemic attacks (TIAs)
and moderate carotid stenosis who has undergone a carotid endarterectomy.
Which of the following postoperative findings would cause the nurse the most
concern?
a) Blood pressure (BP): 128/86 mm Hg
b) Neck pain: 3/10 (0 to 10 pain scale)
c) Mild neck edema
d) Difficulty swallowing - ANS Difficulty swallowing
The patient's inability to swallow without difficulty would cause the nurse the
most concern. Difficulty in swallowing, hoarseness or other signs of cranial nerve
dysfunction must be assessed. The nurse focuses on assessment of the following
cranial nerves: facial (VII), vagus (X), spinal accessory (XI), and hypoglossal (XII).
Some edema in the neck after surgery is expected; however, extensive edema and
hematoma formation can obstruct the airway. Emergency airway supplies,
including those needed for a tracheostomy, must be available. The patient's neck
pain and mild BP elevation need addressing but would not cause the nurse the
most concern. Hypotension is avoided to prevent cerebral ischemia and
,thrombosis. Uncontrolled hypertension may precipitate cerebral hemorrhage,
edema, hemorrhage at the surgical incision, or disruption of the arterial
reconstruction.
An emergency department nurse is interviewing a client with signs of an ischemic
stroke that began 2 hours ago. The client reports that she had a cholecystectomy 6
weeks ago and is taking digoxin, coumadin, and labetelol. This client is not eligible
for thrombolytic therapy for which of the following reasons?
a) She is not within the treatment time window.
b) She had surgery 6 weeks ago.
c) She is taking digoxin.
d) She is taking coumadin. - ANS She is taking coumadin.
To be eligible for thrombolytic therapy, the client cannot be taking coumadin.
Initiation of thrombolytic therapy must be within 3 hours in clients with ischemic
stroke. The client is not eligible for thrombolytic therapy if she has had surgery
within 14 days. Digoxin and labetelol do not prohibit thrombolytic therapy.
Which disturbance results in loss of half of the visual field?
,a) Anisocoria
b) Homonymous hemianopsia
c) Nystagmus
d) Diplopia - ANS Homonymous hemianopsia
Homonymous hemianopsia (loss of half of the visual field) may occur from stroke
and may be temporary or permanent. Double vision is documented as diplopia.
Nystagmus is ocular bobbing and may be seen in multiple sclerosis. Anisocoria is
unequal pupils.
A client with a cerebrovascular accident (CVA) is having difficulty with eating food
on the plate. Which is the best nursing action to be taken?
a) Reposition the tray and plate.
b) Perform a vision field assessment.
c) Know this is a normal finding for CVA.
d) Assist the client with feeding. - ANS Perform a vision field assessment.
, The nurse should perform a vision field assessment to evaluate the client
forhemianopia. 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. (less)
A client is hospitalized when they present to the Emergency Department with
right-sided weakness. Within 6 hours of being admitted, the neurologic deficits
had resolved and the client was back to their presymptomatic state. The nurse
caring for the client knows that the probable cause of the neurologic deficit was
what?
a) Cerebral aneurysm
b) Transient ischemic attack
c) Left-sided stroke
d) Right-sided stroke - ANS Transient ischemic attack
A transient ischemic attack (TIA) is a sudden, brief attack of neurologic impairment
caused by a temporary interruption in cerebral blood flow. Symptoms may
disappear within 1 hour; some continue for as long as 1 day. When the symptoms
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