ch 62 Cerebrovascular disorders Flashcards
(39 cards)
a nurse is assisting a client who had a recent stroke with getting dressed for physical therapy. The client looks at each piece of clothing before putting it on the body. The client states, “This is how I know what item I am holding.” What impairment is this client likely experiencing?
Agnosia
a client with a left hemispheric stroke is having difficulty with their normal speech patterns. The nurse is not sure whether the client has expressive aphasia or apraxia. Which statement would most likely be reflective of apraxia?
the client starts by saying “good morning” but finishes with saying “good day” to the nurse
a client with a recent stroke history is admitted to a rehabilitation unit and placed on high fall risk precautions. The client is impulsive, easily distracted, frequently forgets their cane when walking, and location of their room. What stroke conditions do these signs best indicate?
right hemispheric stroke
a client diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for which purpose?
to remove atherosclerotic plaques blocking cerebral flow
the nurse is discharging home a client who had a stoke. The client has a flaccid right arm and leg and is experiencing urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common client response to a change in body image?
depression
the nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration?
alteration in level of consciousness (LOC)
a client with an ischemic stroke has been brought to the emergency room. The health care provider institutes measures to restore cerebral blood flow. What area of the brain would most likely benefit from this immediate intervention?
penumbra region
what are priority interventions for a client who is currently on anticoagulant therapy and having an ischemic stroke?
supplemental oxygen and monitoring blood glucose levels
a client with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this client?
absolute bed rest in a quiet, non-stimulating environment
a client recovering from a stroke has severe shoulder pain from subluxation of the shoulder. To prevent further injury and pain, the nurse caring for this client is aware of what principle of care?
the client should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder
the client has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the client’s atmosphere more conducive to communication?
provide a board of commonly used needs and phrases
the nurse is assessing a client with a suspected stroke. what assessment finding is most suggestive of a stroke?
facial droop
the nurse is caring for a client diagnosed with ischemic stroke and knows that effective positioning of the client it’s important. Which of the following should be integrated into the client’s plan of care?
the client should be placed in a prone position for 15 to 30 minutes several times a day
the nurse is educating a group of students about complications of an aneurysm. Which is a complication of aneurysm?
seizure
a nurse is caring for a client diagnosed with a hemorrhagic stroke. When creating this client’s plan of care, what goal should be prioritized?
maintain and improve cerebral tissue perfusion
the nurse is preparing health education for a client who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in this education?
take antihypertensive medication as prescribed
a client diagnosed with a cerebral aneurysm reports a sever headache to the nurse. What action is a priority for the nurse?
call the health care provider immediately
a client is brought by ambulance to the ED after suffering a stroke. The nurse caring for this client is aware that an absolute contraindication for thrombolytic therapy is what?
evidence of hemorrhagic stroke
when caring for a client who has had a stoke, a priority is reduction of ICP. What client position is most consistent with this goal?
elevation of the head of the bed
a client who suffered an ischemic stoke now had disturbed sensory perception. What principle should guide the nurse’s care of this client?
the client should be approached on the side where visual perceptions is intact
what should be included in the client’s care plan when establishing an exercise program for a client affected by a stroke?
exercise the affected extremities passively four or five times a day
a client is diagnosed with a right sided stroke. The client is now experiencing hemianopsia. how might the nurse help the client manage the potential sensory and perceptional difficulties?
place the client’s extremities where the client can see them
a client recently had a stroke. Now the client has spasms in his/her hands, which is preventing a favorite hobby of knitting. The client is looking for a permanent solution to this problem. Which therapies would the nurse recommend?
Baclofen and stretching
a client who has experienced an ischemic stoke has been admitted to the medical unit. the family is adamant that the client remain on bed rest to hasten recovery and to conserve energy. what principle of care should inform the nurse’s response to the family?
the client should mobilize as soon as physically able to
