Stroke & Seizure

Study online at https://quizlet.com/_18s9rd

2. A client with a subarachnoid hemorrhage is prescribed a
1,000-mg loading dose of Dilantin IV. Which consideration is most
Answer: 2. Dilantin IV shouldn't be given at a rate exceeding 50
important when administering this dose?
mg/minute. Rapid administration can depress the myocardium,
causing arrhythmias. Therapeutic drug levels range from 10 to 20
1. Therapeutic drug levels should be maintained between 20 to 30
mg/ml. Dilantin shouldn't be mixed in solution for administration.
mg/ml.
However, because it's compatible with normal saline solution, it
2. Rapid dilantin administration can cause cardiac arrhythmias.
can be injected through an IV line containing normal saline. When
3. Dilantin should be mixed in dextrose in water before adminis-
given through an IV catheter hand, dilantin may cause purple glove
tration.
syndrome.
4. Dilantin should be administered through an IV catheter in the
client's hand.
4. When evaluating an ABG from a client with a subdural
hematoma, the nurse notes the PaCO2 is 30 mm Hg. Which of
Answer: 1. A normal PaCO2 value is 35 to 45 mm Hg. CO2
the following responses best describes this result?
has vasodilating properties; therefore, lowering PaCO2 through
hyperventilation will lower ICP caused by dilated cerebral ves-
1. Appropriate; lowering carbon dioxide (CO2) reduces intracranial
sels. Oxygenation is evaluated through PaO2 and oxygen satu-
pressure (ICP).
ration. Alveolar hypoventilation would be reflected in an increased
2. Emergent; the client is poorly oxygenated.
PaCO2.
3. Normal
4. Significant; the client has alveolar hypoventilation.
5. A client who had a transsphenoidal hypophysectomy should be
watched carefully for hemorrhage, which may be shown by which
of the following signs?
Answer: 2. Frequent swallowing after brain surgery may indicate
fluid or blood leaking from the sinuses into the oropharynx. Blood
1. Bloody drainage from the ears
or fluid draining from the ear may indicate a basilar skull fracture.
2. Frequent swallowing
3. Guaiac-positive stools
4. Hematuria
18. Which of the following clients on the rehab unit is most likely
to develop autonomic dysreflexia?
Answer: 3. Autonomic dysreflexia refers to uninhibited sympathetic
1. A client with a brain injury outflow in clients with spinal cord injuries about the level of T10.
2. A client with a herniated nucleus pulposus The other clients aren't prone to dysreflexia.
3. A client with a high cervical spine injury
4. A client with a stroke
28. The nurse is discussing the purpose of an electroencephalo-
gram (EEG) with the family of a client with massive cerebral
hemorrhage and loss of consciousness. It would be most accurate
for the nurse to tell family members that the test measures which Answer: 3. An EEG measures the electrical activity of the brain.
of the following conditions? Extent of intracranial bleeding and location of the injury site would
be determined by CT or MRI. Percent of functional brain tissue
1. Extent of intracranial bleeding would be determined by a series of tests.
2. Sites of brain injury
3. Activity of the brain
4. Percent of functional brain tissue
29. A client arrives at the ER after slipping on a patch of ice and
hitting her head. A CT scan of the head shows a collection of blood
Answer: 3. An epidural hematoma occurs when blood collects
between the skull and dura mater. Which type of head injury does
between the skull and the dura mater. In a subdural hematoma,
this finding suggest?
venous blood collects between the dura mater and the arachnoid
mater. In a subarachnoid hemorrhage, blood collects between the
1. Subdural hematoma
pia mater and arachnoid membrane. A contusion is a bruise on
2. Subarachnoid hemorrhage
the brain's surface.
3. Epidural hematoma
4. Contusion
1. Regular oral hygiene is an essential intervention for the client
who has had a stroke. Which of the following nursing measures is Answer: 1. A helpless client should be positioned on the side, not
inappropriate when providing oral hygiene? on the back. This lateral position helps secretions escape from
the throat and mouth, minimizing the risk of aspiration. It may be
1. Placing the client on the back with a small pillow under the head. necessary to suction, so having suction equipment at the bedside
2. Keeping portable suctioning equipment at the bedside.
1/5
 Stroke & Seizure
Study online at https://quizlet.com/_18s9rd
3. Opening the client's mouth with a padded tongue blade. is necessary. Padded tongue blades are safe to use. A toothbrush
4. Cleaning the client's mouth and teeth with a toothbrush. is appropriate to use.
2. A 78 year old client is admitted to the emergency department Answer: 3. A CT scan will determine if the client is having a stroke
with numbness and weakness of the left arm and slurred speech. or has a brain tumor or another neurological disorder. This would
Which nursing intervention is priority? also determine if it is a hemorrhagic or ischemic accident and
guide the treatment, because only an ischemic stroke can use
1. Prepare to administer recombinant tissue plasminogen activa- rt-PA. This would make (1) not the priority since if a stroke was
tor (rt-PA). determined to be hemorrhagic, rt-PA is contraindicated. Discuss
2. Discuss the precipitating factors that caused the symptoms. the precipitating factors for teaching would not be a priority and
3. Schedule for A STAT computer tomography (CT) scan of the slurred speech would as indicate interference for teaching. Refer-
head. ring the client for speech therapy would be an intervention after the
4. Notify the speech pathologist for an emergency consult. CVA emergency treatment is administered according to protocol.
3. A client arrives in the emergency department with an ischemic
stroke and receives tissue plasminogen activator (t-PA) adminis- Answer: 3. The time of onset of a stroke to t-PA administration
tration. Which is the priority nursing assessment? is critical. Administration within 3 hours has better outcomes. A
complete history is not possible in emergency care. Upcoming
1. Current medications. surgical procedures will need to be delay if t-PA is administered.
2. Complete physical and history. Current medications are relevant, but onset of current stroke takes
3. Time of onset of current stroke. priority.
4. Upcoming surgical procedures.
4. During the first 24 hours after thrombolytic therapy for ischemic
Answer: 3. Controlling the blood pressure is critical because an
stroke, the primary goal is to control the client's:
intracerebral hemorrhage is the major adverse effect of throm-
bolytic therapy. Blood pressure should be maintained according to
1. Pulse
physician and is specific to the client's ischemic tissue needs and
2. Respirations
risks of bleeding from treatment. Other vital signs are monitored,
3. Blood pressure
but the priority is blood pressure.
4. Temperature
5. What is a priority nursing assessment in the first 24 hours after Answer: 2. It is crucial to monitor the pupil size and pupillary
admission of the client with a thrombotic stroke? response to indicate changes around the cranial nerves. Cho-
lesterol level is an assessment to be addressed for long-term
1. Cholesterol level healthy lifestyle rehabilitation. Bowel sounds need to be assessed
2. Pupil size and pupillary response because an ileus or constipation can develop, but is not a priority
3. Vowel sounds in the first 24 hours. An echocardiogram is not needed for the client
4. Echocardiogram with a thrombotic stroke.
6. What is the expected outcome of thrombolytic drug therapy?

1. Increased vascular permeability. Answer: 3. Thrombolytic therapy is use to dissolve emboli and
2. Vasoconstriction. reestablish cerebral perfusion.
3. Dissolved emboli.
4. Prevention of hemorrhage
7. The client diagnosed with atrial fibrillation has experienced a
Answer: 1. Thrombi form secondary to atrial fibrillation, there-
transient ischemic attack (TIA). Which medication would the nurse
fore, an anticoagulant would be anticipated to prevent thrombi
anticipate being ordered for the client on discharge?
formation; and oral (warfarin [Coumadin]) at discharge verses
intravenous. Beta blockers slow the heart rate and lower the blood
1. An oral anticoagulant medication.
pressure. Anti-hyperuricemic medication is given to clients with
2. A beta-blocker medication.
gout. Thrombolytic medication might have been given at initial
3. An anti-hyperuricemic medication.
presentation but would not be a drug prescribed at discharge.
4. A thrombolytic medication.
8. Which client would the nurse identify as being most at risk for
experiencing a CVA? Answer: 1. Africana Americans have twice the rate of CVA's as
Caucasians; males are more likely to have strokes than females
1. A 55-year-old African American male. except in advanced years. Oriental's have a lower risk, possibly
2. An 84-year-old Japanese female. due to their high omega-3 fatty acids. Pregnancy is a minimal risk
3. A 67-year-old Caucasian male. factor for CVA.
4. A 39-year-old pregnant female.

9. Which assessment data would indicate to the nurse that the Answer: 3. Uncontrolled hypertension is a risk factor for hemor-
client would be at risk for a hemorrhagic stroke? rhagic stroke, which is a rupture blood vessel in the cranium. A
bruit in the carotid artery would predispose a client to an embolic
1. A blood glucose level of 480 mg/dl. or ischemic stroke. High blood glucose levels could predispose a

2/5
 Stroke & Seizure
Study online at https://quizlet.com/_18s9rd
2. A right-sided carotid bruit.
patient to ischemic stroke, but not hemorrhagic. Cancer is not a
3. A blood pressure of 220/120 mmHg.
precursor to stroke.
4. The presence of bronchogenic carcinoma.
10. The nurse and unlicensed assistive personnel (UAP) are car-
ing for a client with right-sided paralysis. Which action by the UAP
requires the nurse to intervene?

1. The assistant places a gait belt around the client's waist prior Answer: 3. This action is inappropriate and would require interven-
to ambulating. tion by the nurse because pulling on a flaccid shoulder joint could
2. The assistant places the client on the back with the client's head cause shoulder dislocation; as always use a lift sheet for the client
to the side. and nurse safety. All the other actions are appropriate.
3. The assistant places her hand under the client's right axilla to
help him/her move up in bed.
4. The assistant praises the client for attempting to perform ADL's
independently.
1. A client admitted to the hospital with a subarachnoid hemor-
rhage has complaints of severe headache, nuchal rigidity, and Answer: 2. Sudden removal of CSF results in pressures lower in
projectile vomiting. The nurse knows lumbar puncture (LP) would the lumbar area than the brain and favors herniation of the brain;
be contraindicated in this client in which of the following circum- therefore, LP is contraindicated with increased ICP. Vomiting may
stances? be caused by reasons other than increased ICP; therefore, LP
isn't strictly contraindicated. An LP may be performed on clients
1. Vomiting continues needing mechanical ventilation. Blood in the CSF is diagnostic
2. Intracranial pressure (ICP) is increased for subarachnoid hemorrhage and was obtained before signs and
3. The client needs mechanical ventilation symptoms of ICP.
4. Blood is anticipated in the cerebrospinal fluid (CSF)
5. Which of the following symptoms may occur with a phenytoin
level of 32 mg/dl? Answer: 1. A therapeutic phenytoin level is 10 to 20 mg/dl. A level of
32 mg/dl indicates toxicity. Symptoms of toxicity include confusion
1. Ataxia and confusion and ataxia. Phenytoin doesn't cause hyponatremia, seizure, or
2. Sodium depletion urinary incontinence. Incontinence may occur during or after a
3. Tonic-clonic seizure seizure.
4. Urinary incontinence
7. Problems with memory and learning would relate to which of
the following lobes? Answer: 4. The temporal lobe functions to regulate memory and
learning problems because of the integration of the hippocampus.
1. Frontal The frontal lobe primarily functions to regulate thinking, planning,
2. Occipital and judgment. The occipital lobe functions regulate vision. The
3. Parietal parietal lobe primarily functions with sensory function.
4. Temporal
10. The client is having a lumbar puncture performed. The nurse
would plan to place the client in which position for the procedure?
Answer: 1. The client undergoing lumbar puncture is positioned
1. Side-lying, with legs pulled up and head bent down onto the lying on the side, with the legs pulled up to the abdomen, and with
chest the head bent down onto the chest. This position helps to open the
2. Side-lying, with a pillow under the hip spaces between the vertebrae.
3. Prone, in a slight Trendelenburg's position
4. Prone, with a pillow under the abdomen.
Answer B. When used to treat status epilepticus, diazepam may be
8. Shortly after admission to an acute care facility, a male client
given every 10 to 15 minutes, as needed, to a maximum dose of 30
with a seizure disorder develops status epilepticus. The physician
mg. The nurse can repeat the regimen in 2 to 4 hours, if necessary,
orders diazepam (Valium) 10 mg I.V. stat. How soon can the nurse
but the total dose shouldn't exceed 100 mg in 24 hours. The
administer a second dose of diazepam, if needed and prescribed?
nurse must not administer I.V. diazepam faster than 5 mg/minute.
Therefore, the dose can't be repeated in 30 to 45 seconds because
A. In 30 to 45 seconds
the first dose wouldn't have been administered completely by that
B. In 10 to 15 minutes
time. Waiting longer than 15 minutes to repeat the dose would
C. In 30 to 45 minutes
increase the client's risk of complications associated with status
D. In 1 to 2 hours
epilepticus.
Answer B. Using a mirror enables the client to inspect all areas of
14. A female client who's paralyzed on the left side has been
the skin for signs of breakdown without the help of staff or family
receiving physical therapy and attending teaching sessions about
members. The client should keep the side rails up to help with
3/5
 Stroke & Seizure
Study online at https://quizlet.com/_18s9rd
safety. Which behavior indicates that the client accurately under- repositioning and to prevent falls. The paralyzed client should take
stands safety measures related to paralysis? responsibility for repositioning or for reminding the staff to assist
with it, if needed. A client with left-side paralysis may not realize
A. The client leaves the side rails down. that the left arm is hanging over the side of the wheelchair. How-
B. The client uses a mirror to inspect the skin. ever, the nurse should call this to the client's attention because
C. The client repositions only after being reminded to do so. the arm can get caught in the wheel spokes or develop impaired
D. The client hangs the left arm over the side of the wheelchair. circulation from being in a dependent position for too long.
15. A male client in the emergency department has a suspected
neurologic disorder. To assess gait, the nurse asks the client to
take a few steps; with each step, the client's feet make a half circle. Answer C. A helicopod gait is an abnormal gait in which the client's
To document the client's gait, the nurse should use which term? feet make a half circle with each step. An ataxic gait is staggering
and unsteady. In a dystrophic gait, the client waddles with the legs
A. Ataxic far apart. In a steppage gait, the feet and toes raise high off the
B. Dystrophic floor and the heel comes down heavily with each step.
C. Helicopod
D. Steppage
29. The nurse is caring for a male client diagnosed with a cerebral
aneurysm who reports a severe headache. Which action should Answer D. The headache may be an indication that the aneurysm
the nurse perform? is leaking. The nurse should notify the physician immediately.
Sitting with the client is appropriate but only after the physician
A. Sit with the client for a few minutes. has been notified of the change in the client's condition. The
B. Administer an analgesic. physician will decide whether or not administration of an analgesic
C. Inform the nurse manager. is indicated. Informing the nurse manager isn't necessary.
D. Call the physician immediately.
1. A white female client is admitted to an acute care facility with a
diagnosis of cerebrovascular accident (CVA). Her history reveals Answer C. Obesity is a risk factor for CVA. Other risk factors
bronchial asthma, exogenous obesity, and iron deficiency anemia. include a history of ischemic episodes, cardiovascular disease,
Which history finding is a risk factor for CVA? diabetes mellitus, atherosclerosis of the cranial vessels, hyper-
tension, polycythemia, smoking, hypercholesterolemia, oral con-
A. Caucasian race traceptive use, emotional stress, family history of CVA, and ad-
B. Female sex vancing age. The client's race, sex, and bronchial asthma aren't
C. Obesity risk factors for CVA.
D. Bronchial asthma
3. A male client is having a tonic-clonic seizures. What should the
nurse do first? Answer D. Protecting the client from injury is the immediate priority
during a seizure. Elevating the head of the bed would have no
A. Elevate the head of the bed. effect on the client's condition or safety. Restraining the client's
B. Restrain the client's arms and legs. arms and legs could cause injury. Placing a tongue blade or other
C. Place a tongue blade in the client's mouth. object in the client's mouth could damage the teeth.
D. Take measures to prevent injury.
10. For a male client with suspected increased intracranial pres-
Answer C. The goal of treatment is to prevent acidemia by elimi-
sure (ICP), a most appropriate respiratory goal is to:
nating carbon dioxide. That is because an acid environment in the
brain causes cerebral vessels to dilate and therefore increases
A. prevent respiratory alkalosis.
ICP. Preventing respiratory alkalosis and lowering arterial pH may
B. lower arterial pH.
bring about acidosis, an undesirable condition in this case. It isn't
C. promote carbon dioxide elimination.
necessary to maintain a PaO2 as high as 80 mm Hg; 60 mm Hg
D. maintain partial pressure of arterial oxygen (PaO2) above 80
will adequately oxygenate most clients.
mm Hg
15. The nurse is positioning the female client with increased
Answer B. The head of the client with increased intracranial pres-
intracranial pressure. Which of the following positions would the
sure should be positioned so the head is in a neutral midline
nurse avoid?
position. The nurse should avoid flexing or extending the client's
neck or turning the head side to side. The head of the bed should
A. Head mildline
be raised to 30 to 45 degrees. Use of proper positions promotes
B. Head turned to the side
venous drainage from the cranium to keep intracranial pressure
C. Neck in neutral position
down.
D. Head of bed elevated 30 to 45 degrees
Answer B. Nursing actions during a seizure include providing for
18. The nurse is caring for the male client who begins to experi-
privacy, loosening restrictive clothing, removing the pillow and
ence seizure activity while in beD. Which of the following actions
raising side rails in the bed, and placing the client on one side
by the nurse would be contraindicated?
with the head flexed forward, if possible, to allow the tongue to
4/5
 Stroke & Seizure
Study online at https://quizlet.com/_18s9rd
fall forward and facilitate drainage. The limbs are never restrained
A. Loosening restrictive clothing because the strong muscle contractions could cause the client
B. Restraining the client's limbs harm. If the client is not in bed when seizure activity begins, the
C. Removing the pillow and raising padded side rails nurse lowers the client to the floor, if possible, protects the head
D. Positioning the client to side, if possible, with the head flexed from injury, and moves furniture that may injure the client. Other
forward aspects of care are as described for the client who is in bed.
19. The nurse is assigned to care for a female client with complete
right-sided hemiparesis. The nurse plans care knowing that this
condition:
Answer B. Hemiparesis is a weakness of one side of the body
that may occur after a stroke. Complete hemiparesis is weakness
A. The client has complete bilateral paralysis of the arms and legs.
of the face and tongue, arm, and leg on one side. Complete
B. The client has weakness on the right side of the body, including
bilateral paralysis does not occur in this condition. The client with
the face and tongue.
right-sided hemiparesis has weakness of the right arm and leg
C. The client has lost the ability to move the right arm but is able
and needs assistance with feeding, bathing, and ambulating.
to walk independently.
D. The client has lost the ability to move the right arm but is able
to walk independently.
20. The client with a brain attack (stroke) has residual dysphagiA.
When a diet order is initiated, the nurse avoids doing which of the
Answer A. Before the client with dysphagia is started on a diet,
following?
the gag and swallow reflexes must have returned. The client is
assisted with meals as needed and is given ample time to chew
A. Giving the client thin liquids
and swallow. Food is placed on the unaffected side of the mouth.
B. Thickening liquids to the consistency of oatmeal
Liquids are thickened to avoid aspiration.
C. Placing food on the unaffected side of the mouth
D. Allowing plenty of time for chewing and swallowing
21. The nurse is assessing the adaptation of the female client to
changes in functional status after a brain attack (stroke). The nurse
Answer D. Clients are evaluated as coping successfully with
assesses that the client is adapting most successfully if the client:
lifestyle changes after a brain attack (stroke) if they make ap-
propriate lifestyle alterations, use the assistance of others, and
A. Gets angry with family if they interrupt a task
have appropriate social interactions. Options A, B, and C are not
B. Experiences bouts of depression and irritability
adaptive behaviors.
C. Has difficulty with using modified feeding utensils
D. Consistently uses adaptive equipment in dressing self
Answer C. Clients with aphasia after brain attack (stroke) often
22. Nurse Kristine is trying to communicate with a client with brain
fatigue easily and have a short attention span. General guidelines
attack (stroke) and aphasiA. Which of the following actions by the
when trying to communicate with the aphasic client include speak-
nurse would be least helpful to the client?
ing more slowly and allowing adequate response time, listening
to and watching attempts to communicate, and trying to put the
A. Speaking to the client at a slower rate
client at ease with a caring and understanding manner. The nurse
B. Allowing plenty of time for the client to respond
would avoid shouting (because the client is not deaf), appearing
C. Completing the sentences that the client cannot finish
rushed for a response, and letting family members provide all the
D. Looking directly at the client during attempts at speech
responses for the client.

5/5