Chapter 57: StrokeLewis: Medical -Surgical Nursing, 10th Edition/TEST BANK FOR MEDICAL SURGICAL NURSING 11TH EDITION IGNATAVICIUS After a patient experienced a brief episode of tinnit us, diplopia, and dysarthria with no residual effects, the nurse anticipates teaching the patient about a. cerebral aneurysm clipping. b. heparin intravenous infusion. c. oral low -dose aspirin therapy. d. tissue plasminogen activator (tPA). - ANSWER -
ANS: C The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent a stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic str oke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA. A patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should con sult with the health care provider before giving the prescribed aspirin? a. The patient has dysphasia. b. The patient has atrial fibrillation. c. The patient reports that symptoms began with a severe headache. d. The patient has a history of brief episodes of right -sided hemiplegia. - ANSWER -ANS: C A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack are not contraindications to aspirin use. A patient with a stroke experiences facial drooping on the right side and right -sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find? a. Impulsive behavior b. Right -sided neglect c. Hyperactive left -sided tendon reflexes d. Difficulty comprehending instructions - ANSWER -
ANS: D Right -sided paralysis indicates a left -brain stroke, which will lead to difficulty with comprehension and use of language. The left -side reflexes are likely to be intact. Impulsive behavior and neglect are more likely with a right -side stroke. During the change of shift report, a nurse is told that a patient has an occluded left posterior cerebral artery. The nurse will anticipate that the patient may have a. dysphasia. b. confusion. c. visual deficits. d. poor judgment. - ANSWER -ANS: C
ANS: C The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent a stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic str oke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA. A patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should con sult with the health care provider before giving the prescribed aspirin? a. The patient has dysphasia. b. The patient has atrial fibrillation. c. The patient reports that symptoms began with a severe headache. d. The patient has a history of brief episodes of right -sided hemiplegia. - ANSWER -ANS: C A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack are not contraindications to aspirin use. A patient with a stroke experiences facial drooping on the right side and right -sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find? a. Impulsive behavior b. Right -sided neglect c. Hyperactive left -sided tendon reflexes d. Difficulty comprehending instructions - ANSWER -
ANS: D Right -sided paralysis indicates a left -brain stroke, which will lead to difficulty with comprehension and use of language. The left -side reflexes are likely to be intact. Impulsive behavior and neglect are more likely with a right -side stroke. During the change of shift report, a nurse is told that a patient has an occluded left posterior cerebral artery. The nurse will anticipate that the patient may have a. dysphasia. b. confusion. c. visual deficits. d. poor judgment. - ANSWER -ANS: C
