Black & Hawks: Medical-Surgical Nursing: Clinical Management for Positive

Outcomes, 7th Edition

Chapter 72: Management of Clients with Stroke

MULTIPLE CHOICE

1. The nurse encourages a stroke victim by reminding him that following a cerebrovascular
accident (CVA) due to thrombosis, the client's condition may improve after several days as a
result of
a. formation of collateral blood circulation.
b. decrease of edema in the area.
c. formation of new nervous pathways.
d. reabsorption of the thrombus.
ANS: b
The area of edema after ischemia may lead to temporary neurologic deficits. Edema may subside
in a few hours or sometimes in several days, and the client may regain some function.

DIF: Cognitive Level: Comprehension REF: Text Reference: 2121

TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity

2. When the wife of a client who has had a CVA as a result of a cerebral hemorrhage asks the
nurse about her husband’s chances for recovery, the nurse should base a reply on knowledge
that with this type of CVA
a. there is no way to know for sure.
b. rapid improvement often occurs.
c. improvement generally occurs over several days.
d. recovery is slow and less complete.
ANS: d
Hemorrhagic strokes usually produce extensive residual function loss and have the slowest
recovery of all types of stroke.

DIF: Cognitive Level: Application REF: Text Reference: 2109

TOP: Nursing Process Step: Intervention
MSC: NCLEX: Psychosocial Integrity

3. The nurse assesses agnosia in a client who had a CVA. An example of this disturbance would
be
a. ability to move a limb but not use it purposefully.
b. inability to see past the midline.
c. inability to read.
d. inability to recognize eating utensils.
ANS: d
Chapter 72: Management of Clients with Stroke 2

Agnosia is a disturbance in the ability to recognize familiar objects through the senses. The most
common types are visual and auditory. A client with visual agnosia may examine objects
curiously but be unable to determine their function.

DIF: Cognitive Level: Application REF: Text Reference: 2114

TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

4. A client is admitted to the hospital with right-sided hemiplegia as a result of a stroke. To help
prevent contractures, the nurse should position the client
a. on the right side as much as possible.
b. on the left side with brief periods on the back and right side.
c. upright as long as tolerated.
d. supine with a pillow under the knees.
ANS: b
Change the position of a client with hemiplegia or decreased level of consciousness (LOC) every
2 hours. The client may be able to tolerate lying only for 30 minutes on the affected side because
of the impaired circulation or pain.

DIF: Cognitive Level: Application REF: Text Reference: 2127

TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity

5. In clients with diplopia, an eye patch over one eye removes the second image and promotes
better vision.When a client complains of the effects of diplopia after a stroke, the nurse
would
a. teach eye muscle exercises.
b. reassure the client that the problem is temporary.
c. place a patch over one eye.
d. approach the client on the unaffected side.
ANS: 3
DIF: Cognitive Level: Application REF: Text Reference: 2128
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity

6. When a client has undergone a carotid endarterectomy and has been returned to the nursing
unit with stable vital signs, the nurse should
a. provide neck range-of-motion exercises every 8 hours.
b. maintain the client in a flat, supine position with the head flexed.
c. maintain blood pressure within 20 mm Hg of the preoperative values.
d. assess neurologic status every 4 hours.
ANS: c

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Chapter 72: Management of Clients with Stroke 3

Postoperative care after carotid endarterectomy includes neurologic assessments every 1 to 2

hours. Keep the client's head aligned in a straight position to help maintain airway patency and to
minimize stress on the operative site. Elevate the head of the bed when vital signs are stable.
Maintain the client's blood pressure within 20 mm Hg of the preoperative normal values.

DIF: Cognitive Level: Application REF: Text Reference: 2135

TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity

7. Two weeks following endarterectomy the ambulatory care nurse notes that a client.'s voice is
weak and hoarse. The nurse explains that this may be due to
a. damage to the vagus nerve.
b. excessive swelling of the neck.
c. damage from endotracheal intubation.
d. Horner's syndrome.
ANS: b
Cranial nerve dysfunction is usually temporary but may last for months. The most common
cranial nerve damage causes vocal cords paralysis, difficulty managing saliva, and tongue
deviation.

DIF: Cognitive Level: Analysis REF: Text Reference: 2135

TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

8. The critical care nurse explains to the family of a client who is to receive nimodipine
following hemorrhagic stroke that the pupose of this drug is to treat
a. vasospasm.
b. hypertension.
c. spasticity.
d. dizziness.
ANS: a
Nimodipine, a calcium-channel blocker, is used to treat vasospasm secondary to subarachnoid
hemorrhage.

DIF: Cognitive Level: Knowledge REF: Text Reference: 2124

TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity

9. The nursing action that would be appropriate in caring for a client who has experienced
stroke due to hemorrhage is to
a. teach isometric exercises.
b. maintain the head of the bed in a flat position.
c. monitor rectal temperature every 4 hours.
d. teach the client to avoid Valsalva's maneuver.
ANS: d

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 Chapter 72: Management of Clients with Stroke 4

Straining at stool or with excessive coughing, vomiting, lifting, or use of the arms to change
position should be avoided, because the Valsalva maneuver increases intracerebral pressure.

DIF: Cognitive Level: Application REF: Text Reference: 2124

TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity

10. An emergency department nurse is admitting a client with ischemic stroke who is eligible for
thrombolytic therapy. The nurse works quickly to provide care, knowing that for this therapy
to be effective, it must be administered in a post-stroke time window of
a. 30 minutes.
b. 3 hours.
c. 6 hours.
d. 12 hours.
ANS: b
Thrombolytic therapy must be administered as soon as possible after the onset of the stroke; a
treatment window of 3 hours from the onset of manifestations has been established.

DIF: Cognitive Level: Knowledge REF: Text Reference: 2107

TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity

11. A client has a history of experiencing focal neurologic deficits, such as slurred speech and
facial weakness, that last for a few hours at a time. The nurse then assesses this client for
other possible manifestations of
a. embolic stroke.
b. encephalopathy.
c. intracranial hemorrhage.
d. transient ischemic attacks (TIAs).
ANS: d
TIAs are focal neurologic deficits lasting less than 24 hours that produce manifestations of
slurred speech, facial weakness, and ataxia.

DIF: Cognitive Level: Analysis REF: Text Reference: 2133

TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

12. A nurse determines that a client newly admitted with stroke has weakness due to right brain
injury. The nurse would document
a. left-sided hemiparesis.
b. left-sided hemiplegia.
c. right-sided hemiparesis.
d. right-sided hemiplegia.
ANS: a

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 Chapter 72: Management of Clients with Stroke 5

Hemiparesis (weakness) or hemiplegia (paralysis) of one side of the body may occur after a
stroke. Infarction in the right side of the brain causes left hemiplegia, and vice versa.

DIF: Cognitive Level: Comprehension REF: Text Reference: 2111

TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

13. A client who has had a stroke appears to understand words that are spoken but cannot
verbally respond. The nurse clarifies that this type of aphasia is
a. receptive.
b. Wernicke's.
c. global.
d. Broca's.
ANS: d
Broca's (expressive or motor) aphasia affects speech production as a result of an infarction in the
frontal lobe of the brain.

DIF: Cognitive Level: Knowledge REF: Text Reference: 2112

TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity

14. The assessment the nurse documents that supports the finding of apraxia would be the
client’s inability to
a. recognize a pencil.
b. understand the spoken word.
c. get dressed independently.
d. see far objects.
ANS: c
In apraxia the client cannot carry out a skilled act such as dressing in the absence of paralysis.

DIF: Cognitive Level: Comprehension REF: Text Reference: 2114

TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

15. The nurse instructs the client with homonymous hemianopsia to compensate for this problem
by
a. wearing an eye patch.
b. using artificial tears.
c. getting evaluated for prescription lenses.
d. turning the head to scan the visual field.
ANS: d
Clients with homonymous hemianopsia cannot see past the midline without turning the head
toward that side.

DIF: Cognitive Level: Application REF: Text Reference: 2114

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 Chapter 72: Management of Clients with Stroke 6

TOP: Nursing Process Step: Intervention

MSC: NCLEX: Physiological Integrity

16. A client who experienced a stroke that left residual left hemiplegia, will not wash the left side
or use her good limbs on the right to move or adust the limbs on the left. The nurse interprets
this behavior as
a. sensory deficits.
b. unilateral neglect.
c. behavioral changes.
d. mood changes.
ANS: b
Clinical manifestations of unilateral neglect include failure (1) to attend to one side of the body,
(2) report or respond to stimuli on one side of the body, (3) use one extremity, and (4) orient the
head and eyes to one side.

DIF: Cognitive Level: Application REF: Text Reference: 2116

TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

17. A client is brought to the emergency department in an unconscious state, with right-sided
paralysis following stroke. The nurse should immediately position the client
a. supine with the head of the bed elevated 45 to 60 degrees.
b. on the right side with the head of the bed elevated 30 degrees.
c. on the left side with the head of the bed elevated 15 degrees.
d. supine with the head of bed flat and neck midline.
ANS: b
The client should be turned on the affected side if he or she is unconscious, to promote drainage
of saliva from the airway.

DIF: Cognitive Level: Application REF: Text Reference: 2116

TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity

18. A client who had a thrombotic stroke finished receiving intravenous rt-PA therapy at 10:00
AM on Sunday. The nurse would question an order for anticoagulant therapy if it was due to
begin before
a. 10:00 PM Sunday.
b. 10:00 AM Monday.
c. 10:00 PM Monday.
d. 10:00 AM Tuesday.
ANS: b
To decrease the risk of intracranial or systemic bleeding, anticoagulants and antiplatelet
medications are not recommended until 24 hours after administration of rt-PA.

DIF: Cognitive Level: Application REF: Text Reference: 2121

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 Chapter 72: Management of Clients with Stroke 7

TOP: Nursing Process Step: Intervention

MSC: NCLEX: Physiological Integrity

19. A client who experienced a stroke is to have a consultation with an occupational therapist in
order to enhance his ability to
a. swallow.
b. feed himself.
c. aquire job skills.
d. use a walker.
ANS: b
Occupational therapists work with the client to relearn activities of daily living (ADLs) and to
use assistive devices.

DIF: Cognitive Level: Comprehension REF: Text Reference: 2123

TOP: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance

20. A client who has left hemiparesis due to stroke is getting out of bed to the chair for the first
time. The nurse should position the chair
a. facing the side of the bed but within 1 foot distance.
b. at the foot of the bed.
c. at a right angle to the client's left side.
d. at a right angle to the client's right side.
ANS: d
It is safest to have the client pivot on the unaffected side. Therefore, position the chair at a right
angle to the unaffected side.

DIF: Cognitive Level: Application REF: Text Reference: 2125

TOP: Nursing Process Step: Intervention
MSC: NCLEX: Safe, Effective Care Environment;

21. In order to prevent external hip rotation in a client with hemiparesis due to stroke,
the nurse should instruct an unlicensed assistive person to use a
a. quad cane.
b. foot splint.
c. high-top sneakers.
d. trochanter roll.
ANS: d
A trochanter roll, extending from the crest of the ilium to midthigh, prevents external hip rotation
by wedging under the projection of the greater trochanter and stopping the femur from rolling.

DIF: Cognitive Level: Knowledge REF: Text Reference: 2127

TOP: Nursing Process Step: Intervention
MSC: NCLEX: Health Promotion and Maintenance

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 Chapter 72: Management of Clients with Stroke 8

22. In the effort to prevent shoulder subluxation during flaccid hemiplegia in a client with stroke,
the nurse should
a. perform passive range-of-motion exercises.
b. encourage active range-of-motion exercises.
c. support the arm with a pillow while in bed or chair.
d. keep the arm abducted 30 to 45 degrees at all times.
ANS: c
The weight of an immobile arm may cause pain and movement limitation (frozen shoulder) or
subluxation of the shoulder joint. Prevent these by supporting a completely flaccid arm with a
pillow when the client is in bed or seated in a chair.

DIF: Cognitive Level: Application REF: Text Reference: 2128

TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity

23. When feeding a client with dysphagia, in order to promote swallowing, the nurse should
a. cut food into large bites to stimulate chewing.
b. give only thickened liquids.
c. place food in the unaffected side of the mouth.
d. have the client tip the head back.
ANS: c
Avoid liquids entirely until the patient is better able to swallow. Place food in the unaffected side
of the mouth. Assist the client to sit upright and lean slightly forward. Begin feeding with foods
that require no chewing and are easy to swallow.

DIF: Cognitive Level: Application REF: Text Reference: 2114

TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity

24. A client with stroke has a nursing diagnosis of Impaired Verbal Communication and has
specific difficulty in verbal expression. The most helpful strategy by the nurse would be to
a. give the client practice in repeating words after the nurse says them.
b. repeat directions until they are understood.
c. point to objects and state their names.
d. try to do all the speaking for the client.
ANS: a
When a client has difficulty with verbal expression, give the client practice in repeating words
after you.

DIF: Cognitive Level: Application REF: Text Reference: 2130

TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity

25. When the client complains about having to perform quadricep setting exercises, the nurse
reminds him that the exercises will enhance ambulation by

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 Chapter 72: Management of Clients with Stroke 9

a. combating footdrop.
b. strengthening the knee.
c. diminishing the effects of proprioception.
d. improving balance.
ANS: b
The quad setting exercises strengthen and stabilize the knee, which is essential to the initiation of
ambulation.

DIF: Cognitive Level: Application REF: Text Reference: 2125

TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity

26. The nurse would assess the client with a history of TIAs for
a. ataxia.
b. bouts of hypertension.
c. nausea.
d. tingling in the extremities.
ANS: a
Manifestations of a TIA in the vertebrobasilar circulation include two or more of the following:
vertigo, diplopia, dysphagia, dysarthria, and ataxia.

DIF: Cognitive Level: Application REF: Text Reference: 2133

TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

27. The nurse caring for a stroke client with stage II dysphagia will offer
a. muffins without seeds.
b. ground meat or tuna.
c. thickened liquids.
d. ice cream.
ANS: a
Muffins without seeds are appropriate for a stage II dysphagic client; thickened liquids, ground
meat, and ice cream are not offered until the client has reached stage III.

DIF: Cognitive Level: Analysis REF: Text Reference: 2114

TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity

Elsevier items and derived items © 2005 by Elsevier Inc.