Chapter 17 My Nursing Test Banks

Wagner, High Acuity Nursing, 6e
Chapter 17

Question 1

Type: MCMA

The nurse is providing community education regarding stroke. Which information should be included?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Stroke is caused by interruption of blood flow to the brain.

2. Stroke is the third-leading cause of death in the United States.

3. Stroke usually occurs simultaneously with myocardial infarction.

4. Rapid recognition of stroke symptoms can help decrease poor outcomes.

5. Stroke causes neurological defects.

Correct Answer: 1,2,4,5

Rationale 1: Stroke occurs when a localized area of the brain is not receiving adequate blood flow. The resultant ischemia causes injury to the brain tissue.

Rationale 2: Stroke is the third cause of death and a leading cause of disability in the United States.

Rationale 3: There is no evidence that stroke and MI generally occur together.

Rationale 4: Rapid recognition of stroke symptoms along with rapid intervention can help to decrease poor outcomes from stroke.

Rationale 5: Neurological changes and deficits are common when stroke occurs.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17-1

Question 2

Type: MCSA

A patient comes into the emergency department with complaints of partial loss of vision in one eye, numbness and tingling of the arm and leg, and dizziness. Which additional information should the nurse initially seek from the patient?

1. If the patient has high blood pressure

2. If the symptoms are still present

3. If this is a recurrent problem

4. If the patient fell

Correct Answer: 2

Rationale 1: Although important, determining if the patient has a history of high blood pressure can be determined at a later time.

Rationale 2: Although all of these issues are important in the assessment of the patient, it is essential to determine if the patient still has the symptoms or if they were time limited. If symptoms are no longer present they are still significant as the patient may have experienced a transient ischemic attack.

Rationale 3: It is important to discern if the patient has ever experienced these symptoms before, but this is not the most important information.

Rationale 4: Assessing if the patient has fallen is not important for the nurse to ask initially.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17-1

Question 3

Type: MCSA

When developing a teaching plan for a patient who had an embolic stroke, the nurse considers which history as a significant risk factor?

1. Hypertension

2. Use of anticoagulants

3. History of atherosclerosis of cerebral arteries

4. Atrial fibrillation

Correct Answer: 4

Rationale 1: Hypertension is more likely associated with thrombotic stroke.

Rationale 2: Use of anticoagulants and hypertension together are associated with hemorrhagic cerebral vascular accidents.

Rationale 3: Atherosclerosis of cerebral arteries is associated with ischemic stroke.

Rationale 4: Atrial fibrillation, in addition to endocarditis, rheumatic heart disease, and recent myocardial infarction, are the most common causes of embolic cerebral vascular accidents.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 17-1

Question 4

Type: MCSA

When planning nursing care for a patient with a cerebral vascular accident, the nurse should consider which primary goal of medical management?

1. Restoration of cerebral blood flow and limiting the size of the infarcted area of the brain

2. Keeping the blood pressure under control pharmacologically

3. Transferring the patient for rehabilitation as soon as medically stable

4. Reestablishing blood flow to the infarcted area surgically

Correct Answer: 1

Rationale 1: The goal is to recover as much function as possible. The most vulnerable area of the brain is the penumbra, and the sooner the circulation can be restored to that area the better the cells in that area will recover.

Rationale 2: The patients blood pressure should be controlled, but this goal is not global enough to be the primary goal.

Rationale 3: Transferring the patient to a long-term care facility as soon as medically stable is a goal for patients to recover enough function to return to their former settings. This is not the primary goal for medical management.

Rationale 4: Surgical options are not available for most stroke patients.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 17-5

Question 5

Type: MCSA

Diagnostic testing reveals that a patient has areas of cerebral focal infarctions. The nurse plans care with the realization that which outcome is likely?

1. The patient will likely deteriorate into multiple system organ failure.

2. These areas of ischemia will likely extend into the brainstem.

3. The patients symptoms will likely resolve with treatment.

4. The patients symptoms will progress rapidly.

Correct Answer: 3

Rationale 1: Multiple system organ failure is not the most likely outcome for this patient.

Rationale 2: Extension of these ischemic areas into the brainstem is not the most likely scenario.

Rationale 3: In focal ischemia there is some degree of collateral circulation that remains. This allows for the survival of neurons and for reversal of neuronal damage after periods of ischemia. Focal ischemia is treatable because of the potential for recovery therefore the patients symptoms will most likely resolve with treatment.

Rationale 4: There is no indication that this patients symptoms will progress rapidly.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 17-2

Question 6

Type: MCSA

A patient with cerebral infarction is experiencing an acceleration of symptoms indicating death of cerebral tissue. The nurse would explain this acceleration as due to which pathophysiology?

1. Increased concentration of sodium, chloride, and calcium in the brain cells

2. Reduced ability of the macrophages to reach the site of injury

3. Reduced concentration of magnesium and phosphorus in the brain cells

4. Increased concentration of potassium in the brain cells

Correct Answer: 1

Rationale 1: Increased intracellular concentrations of sodium, chloride, and calcium are due to the lack of oxygen reaching the cerebral tissues. Without oxygen, these electrolytes accumulate leading to toxicity within the mitochondria. This leads to further cerebral tissue death.

Rationale 2: Cell death due to ischemia is not related to reduced ability of macrophages to reach the site of tissue injury.

Rationale 3: Cell death from ischemia is not related to reduced levels of phosphorus and magnesium in the injured tissue.

Rationale 4: Accelerated cerebral tissue death is not due to an increased concentration of potassium in the brain cells.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17-2

Question 7

Type: MCSA

The nurse is instructing a patient on stroke prevention. Which patient statement would the nurse evaluate as indicating understanding of the presence of a nonmodifiable risk factor for stroke development?

1. I have hypertension just like my mom and her family.

2. Lots of people of my ethnicity suffer strokes.

3. I have tried several times to quit smoking, but I just cant seem to do it.

4. It is going to be hard to give up eating red meat and my favorite family meals just to lower my cholesterol.

Correct Answer: 2

Rationale 1: Even familial hypertension can be modified or controlled to help prevent stroke development.

Rationale 2: Ethnicity is a nonmodifiable risk factor for the development of stroke.

Rationale 3: Smoking cessation is difficult, but achievable and is a modifiable risk factor for stroke development.

Rationale 4: Hyperlipidemia is a controllable risk factor for the development of stroke.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 17-3

Question 8

Type: MCMA

The nurse is assessing a newly admitted older patient for modifiable risk factors for stroke development. The nurse would include teaching about which findings?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Blood pressure is consistently above 95 diastolic.

2. The patient has had two recent hospital admissions to treat dehydration.

3. The patient reports drinking a glass of wine with dinner every evening.

4. The patient uses smokeless tobacco.

5. Testing has previously indicated the patient has hypercholesterolemia.

Correct Answer: 1,2,5

Rationale 1: Diastolic hypertension (consistent readings above 95) is a modifiable risk factor for stroke development.

Rationale 2: Dehydration may cause dangerous lowering of blood pressure and decrease cerebral perfusion, especially in older patients. This decrease in cerebral perfusion may precipitate stroke.

Rationale 3: Moderate alcohol use, such as one glass of wine per day, is not associated with stroke development.

Rationale 4: While smoking does increase risk for stroke, the use of smokeless tobacco has not been shown to have the same effect.

Rationale 5: Hypercholesterolemia is a risk factor for atherosclerosis in the cerebral vascular beds and increases risk for stroke.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17-3

Question 9

Type: MCSA

The nurse is triaging a patient who just presented to the emergency department. Which cluster of assessment findings would the nurse evaluate as indicated the greatest possibility that this patient is having a stroke?

1. Radicular pain, decreased deep tendon reflexes, loss of bladder control

2. Dysphagia, hemianopsia, hemiparesis

3. Dystonia, dysphagia, dysarthria

4. Paresthesia, priaprism, loss of reflexes

Correct Answer: 2

Rationale 1: Radicular pain, decreased deep tendon reflexes, and loss of bladder control are more likely associated with other neurologic conditions rather than stroke.

Rationale 2: The most common cluster of symptoms seen in a stroke is dysphagia, hemianopsia, and hemiparesis.

Rationale 3: Dysphagia is common in stroke, but dystonia and dyarthria are not common findings associated with stroke.

Rationale 4: The patient having stroke may have some paresthesia, but priapism and loss of reflexes are not common initial findings.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17-4

Question 10

Type: MCSA

A patient, admitted with syncope, is diagnosed with an 80% stenosis of the left carotid artery. In addition to assessing the patients speech, the nurse should focus the assessment on the presence or development of which other findings?

1. Vertigo and cranial nerve palsies

2. Monocular blindness and left-sided sensory loss

3. Double vision and ataxia

4. Right sided hemineglect, sensory and motor loss

Correct Answer: 4

Rationale 1: Vertigo and cranial nerve palsies are seen with an altered vertebrobasilar circulation.

Rationale 2: The sensory-motor fibers cross, which means that the sensory and motor deficits will be on the side opposite the stroke, so left-sided sensory or motor loss will not be seen.

Rationale 3:
Double vision and ataxia are seen with an altered vertebrobasilar circulation.

Rationale 4: The sensory-motor fibers cross, which means that the sensory and motor deficits will be on the side opposite the stroke.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17-4

Question 11

Type: MCSA

The nurse is planning care for a patient with a thrombotic stroke in the distribution of the right middle cerebral artery. Which nursing diagnosis is the priority for care in the acute phase of this disease process?

1. Altered Nutrition: Less than Body Requirements

2. Total Self-Care Deficit

3. Decreased Intracranial Aadaptive Capacity

4. Altered Cerebral Tissue Perfusion

Correct Answer: 4

Rationale 1: While alteration of nutrition may occur, it is not the priority in the initial treatment of this condition.

Rationale 2: The patient may experience self-care deficits, but this is not the priority for the initial treatment of this condition.

Rationale 3: In this type of stroke, increased intracranial pressure is generally not a major concern; therefore, decreased intracranial adaptive capacity is not the priority.

Rationale 4: The priority for care in the early and acute phase of a thrombotic stroke is to maintain the effect perfusion to the area near the infarct, the penumbra.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 17-5

Question 12

Type: MCSA

A patient who has been admitted with symptoms of stroke is to have a CT scan. What rationale for this testing would the nurse provide to the patient and family?

1. CT scans are used to determine the effectiveness of the cerebral circulation to perfuse all areas of the brain.

2. The CT scan will evaluate how much brain swelling is associated with this stroke.

3. The CT scan will pinpoint the exact area of the brain affected by the stroke.

4. The CT scan can guide treatment by differentiating hemorrhagic from ischemic causes of the stroke.

Correct Answer: 4

Rationale 1: A CT alone will not determine the effectiveness of cerebral circulation.

Rationale 2: CT scans cannot determine the extent of brain swelling.

Rationale 3: CT scans cannot pinpoint the exact area of the brain affected by stroke, but can help to establish the anatomical region in which the stroke occurred.

Rationale 4: A CT scan will be used to rule out a hemorrhagic stroke from an ischemic stroke especially if thrombolytic therapy is being considered and to determine any areas of localized hematoma formation as a result of a hemorrhage.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17-4

Question 13

Type: MCMA

A patient is receiving tissue plasminogen activator (tPA) for the treatment of an ischemic stroke. Which nursing interventions are indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Insert a nasogastric tube for nutritional support.

2. Monitor for renal stone formation.

3. Monitor for deterioration of neurological status.

4. Reposition every 15 minutes.

Correct Answer: 3

Rationale 1: Insertion of a nasogastric tube can cause injury and should be avoided in this patient.

Rationale 2: Renal stone formation is not a complication of this medication.

Rationale 3: Deterioration of neurological status can occur as a result of bleeding or if tPA is not effective in lysing the clot. The nurse should monitor for this evolving situation.

Rationale 4: Frequent moving can increase the risk of bleeding therefore the patient should not be repositioned every 15 minutes.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17-6

Question 14

Type: MCMA

Which nursing interventions are indicated when providing care for a patient recovering from right carotid endarterectomy?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Position the patient supine on the left side.

2. Teach the patient to hold his head for support when changing positions.

3. Conduct frequent assessments for facial drooping or tongue deviation.

4. Monitor blood pressure level frequently.

5. Perform frequent tracheostomy care.

Correct Answer: 2,3,4

Rationale 1: This patient should be positioned on the right side with the head of the bed elevated 30 degrees to reduce operative site edema.

Rationale 2: Support prevents additional tension on the operative side which could result in bleeding and hematoma formation. The nurse should support the patients head when assisting with position changes and should teach the patient to do so for independent position changes.

Rationale 3: Temporary deficits in cranial nerve function may indicate stretching of these nerves. The nurse should assess for these changes that may indicate need for further intervention.

Rationale 4: Patients who have this procedure are at risk for blood pressure instability due to disruption of the carotid sinus.

Rationale 5: This procedure does not require placement of a tracheostomy.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17-6

Question 15

Type: MCSA

A patient is recovering from surgery to clip an aneurysm. The nurse would anticipate managing which interventions to help prevent cerebral vasospasm?

1. Infusion of packed red blood cells

2. Diuretic therapy

3. Oral fluid restriction

4. Intravenous fluid augmentation

Correct Answer: 4

Rationale 1: While support of volume is important in these patients, nothing in the scenario indicates need for packed red blood cells in this particular situation.

Rationale 2: Diuretic therapy is not indicated as it may result in hypovolemia, which is contraindicated.

Rationale 3: Oral fluid restriction will not support the desired effect of hypervolemia and hemodilution that is indicated for this patient.

Rationale 4: Postoperative complications associated with the clipping of an aneurysm include cerebral vasospasm. Vasospasm decreases perfusion to brain tissue and is prevented and treated with triple H therapy: hypervolemia, hypertension, and hemodilution. This combination of therapies is used to augment cerebral perfusion pressure by raising systolic blood pressure, cardiac output, and intravascular volume to increase cerebral blood flow and minimize cerebral ischemia.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17-5

Question 16

Type: MCSA

A patient is diagnosed with bleeding into the cerebellum. The nurse would prepare this patient for which medical intervention?

1. Angioplasty

2. Immediate surgery to remove the blood from the cerebellum

3. Stent placement

4. Aggressive diuretic therapy to dehydrate cerebral tissues

Correct Answer: 2

Rationale 1: Angioplasty is used to reverse neurological deficits caused by artherosclerotic lesions in the cerebral arteries. It is not indicated for cerebellar bleeding.

Rationale 2: Cerebellar lesions are critical because a hemorrhage or infarction can rapidly become life threatening by compromising the brainstem. Patients with large hemorrhages or infarctions are more likely to have brainstem compression and an urgent need for surgery.

Rationale 3: Stents are placed to hold arteries open. This intervention is not indicated in the face of cerebellar bleeding.

Rationale 4: Diuretic therapy will not decrease the compression of brain tissue that will result from cerebellar bleeding.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17-5

Question 17

Type: MCSA

A patient with spasticity of the upper extremity after a stroke asks why a sling is not used to support the arm. Which rationale should the nurse provide?

1. The use of a sling will reinforce the spasticity and may promote a contracture.

2. A sling will alter your center of balance when standing.

3. The presence of a sling will make it difficult for you to assume responsibility for activities of daily living like dressing.

4. You will not be able to participate in therapy if you get accustomed to your arm being in a sling.

Correct Answer: 1

Rationale 1: Slings limit activity and assist in forming a contracture of the shoulder that will hinder the patients ability to participate in activities of daily living during and after recovery. Slings will also reinforce muscle spasticity.

Rationale 2: Slings do not alter the center of balance.

Rationale 3: Difficulty with assuming responsibilities of daily living is not the rationale for avoiding the use of slings.

Rationale 4: A sling could be removed for therapy sessions, but this is not the correct information to provide to this patient.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17-6

Question 18

Type: MCSA

Which assessment finding supports the nursing diagnosis of Risk for Aspiration in a patient with a cerebral vascular accident?

1. Eating only foods on one side of the tray

2. Refusal to allow the nurse to assist with feeding

3. Absence of interest in eating or drinking

4. Continuous clearing of the throat

Correct Answer: 4

Rationale 1: Eating foods only on one side of a tray represents a sensory perceptual problem related to the stroke.

Rationale 2: Refusal to allow the nurse to assist with feeding indicates psychosocial changes associated with stroke.

Rationale 3: Absence of interest in eating indicates an altered mood, such as depression, related to an altered neurological or health status.

Rationale 4: Continuous clearing of the throat or coughing while eating or drinking indicates that food or fluids are entering the trachea or pooling in the back of the throat. The nurse needs to stop feeding when this is noted and speech therapy should be consulted for a swallowing exam.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17-6

Question 19

Type: MCSA

Which goal would the nurse rank as priority for a patient with stroke-related sensory perception alterations?

1. The patient and caregivers will discuss methods to avoid hazards in the environment.

2. The patient will work to increase perception of sensations.

3. The patient will not experience further loss of sensation.

4. The patient will understand the risk of injury related to decreased sensation.

Correct Answer: 1,3

Rationale 1: This patient has decreased ability to perceive environmental hazards, so the patients and caregivers need to discuss methods to avoid injury related to perception loss.

Rationale 2: The patient has no control over the loss of sensations, so he or she is not able to work to increase perception.

Rationale 3: The patient and the nurse have no control over loss of sensation. This goal is not realistic.

Rationale 4: The nurse cannot measure the patients understanding, so this goal is not correctly written. Even if correctly written, simply understanding the risk is not as important as taking action to avoid risk.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 17-6

Question 20

Type: MCMA

A patient had a stroke which resulted in Brocas aphasia. What instructions should the nurse provide when teaching the family how to communicate with this patient?

Standard Text: Select all that apply.

1. Speak slowly and loudly to the patient.

2. Use paper and pencil for all communication.

3. Ask the patient yes-no questions.

4. Anticipate the patients answers and finish questions and sentences.

5. Give the patient time to search for words.

Correct Answer: 3,5

Rationale 1: Patients who are aphasic often complain that people shout at them as if they cannot hear. A hearing deficit is not a part of Brocas aphasia and speaking loudly is not indicated.

Rationale 2: Writing ability may also be impaired with Brocas aphasia.

Rationale 3: The patient with Brocas aphasia is able to comprehend speech, but has difficulty responding verbally. Asking yes-no questions allows the patient to respond nonverbally.

Rationale 4: The patient with Brocas aphasia may retain some speech. It is not helpful, however, for others to complete the patients questions or sentences.

Rationale 5: Allowing the patient time to search for words may result in adequate expression of needs. It may also help the patient improve word finding, which would improve speech.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17-6

Wagner, High Acuity Nursing, 6/E Test Bank

Copyright 2014 by Pearson Education, Inc.

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