Chapter 22 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 22

Question 1

Type: MCSA

The nurse is discussing stroke etiology with a community group. The nurse would describe which mechanism as causing the most common kind of stroke?

1. Ischemia

2. Hemorrhage

3. Headache

4. Spasm

Correct Answer: 1

Rationale 1: Eighty percent of all strokes are caused by ischemia.

Rationale 2: Hemorrhagic strokes are less common than another type of stroke.

Rationale 3: Headache is a symptom related to stroke but is not a causative mechanism.

Rationale 4: Some strokes are caused by vasospasm, but they are not the predominant type.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 22-1

Question 2

Type: MCSA

A patient is admitted with signs of a stroke (CVA). On admission, vital signs were blood pressure 128/70, pulse 68, and respirations 20. Two hours later the patient is not awake, has a blood pressure of 170/70, pulse 52, and the left pupil is now slower than the right pupil in reacting to light. These findings suggest which condition?

1. Impending brain death

2. Decreasing intracranial pressure

3. Stabilization of the patients condition

4. Increasing intracranial pressure

Correct Answer: 4

Rationale 1: Brain death is diagnosed by a lack of brain waves and inability to maintain vital function.

Rationale 2: Rising systolic blood pressure, falling pulse, and a pupil that has become sluggish suggest increasing another condition.

Rationale 3: This is an emergency situation that requires intervention, as the patients condition is becoming more unstable.

Rationale 4: Rising systolic blood pressure, falling pulse, and a pupil that has become sluggish suggest increasing intracranial pressure (IICP). This is an emergency situation that requires notification of the physician.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 22-1

Question 3

Type: MCSA

A hospitalized patient has become unresponsive. The left side of the body is flaccid. The attending physician believes the patient may

have had a hemorrhagic stroke. What is the nurses priority intervention?

1. Move the patient to the critical care unit.

2. Assess blood pressure.

3. Assess the airway and breathing.

4. Observe urinary output.

Correct Answer: 3

Rationale 1: Moving the patient to the critical care unit is not a priority intervention.

Rationale 2: Blood pressure assessment is an important intervention but not the most vital.

Rationale 3: In any unconscious patient, the airway must be protected. Assessment of the current airway and breathing status is of highest priority and will continue to be.

Rationale 4: Urinary output assessment is an important intervention but not the most vital.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 22-2

Question 4

Type: MCSA

A post-stroke patient is going home on oral Coumadin (warfarin). During discharge teaching, which statement by the patient reflects an understanding of the effects of this medication?

1. I will stop taking this medicine if I notice any bruising.

2. I will not eat spinach while Im taking this medicine.

3. It will be OK for me to eat anything.

4. Ill check my blood pressure frequently while taking this medication.

Correct Answer: 2

Rationale 1: Bruising is a common side effect, and the drug should not be stopped unless by prescriber order.

Rationale 2: Warfarin is a vitamin K antagonist. Green, leafy vegetables contain vitamin K and will therefore interfere with the therapeutic effects of the drug.

Rationale 3: Fatty foods interfere with warfarin therapy.

Rationale 4: This medication does not affect the blood pressure.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 22-2

Question 5

Type: MCSA

The nurse is teaching a wellness class and is discussing the warning signs of stroke. A patient asks, What is the most important thing for me to remember? Which is an appropriate response by the nurse?

1. Know your family history.

2. Keep a list of your medications.

3. Be alert for sudden weakness or numbness.

4. Call 911 if you notice a gradual onset of paralysis or confusion.

Correct Answer: 3

Rationale 1: Family history and past medical history can be indicators for risk, but they are not warning signs of stroke.

Rationale 2: Keeping a list of medications will not assist in identifying a stroke.

Rationale 3: Warning signs of stroke include sudden weakness, paralysis, loss of speech, confusion, dizziness, unsteadiness, and loss of balance. The key word is sudden.

Rationale 4: Gradual onset of symptoms is not indicative of a stroke.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 22-2

Question 6

Type: MCMA

A patient has been hospitalized for scheduled repair of an intracranial aneurysm. The nurse caring for the patient prior to surgery would recognize which manifestations as indicating the aneurysm may be leaking or may have ruptured?

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

Standard Text: Select all that apply.

1. Visual deficits

2. Headache

3. Mild nausea

4. Dilated pupil

5. Stiff neck

Correct Answer: 1,2,4

Rationale 1: The most common cranial nerve signs are dilated pupil, decreased mobility of the eye, and ptosis.

Rationale 2: The most common complaint is the worst headache of my life.

Rationale 3: Nausea is not a prodromal sign, but it may be present once rupture has occurred.

Rationale 4: Pupil dilation is a common prodromal finding.

Rationale 5: Stiff neck is not a prodromal sign of intracranial aneurysm.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 22-4

Question 7

Type: MCMA

A patient has undergone repair of a subarachnoid hemorrhage. The nurse should monitor this patient for development of which complications?

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

Standard Text: Select all that apply.

1. Hypernatremia

2. Hydrocephalus

3. Rebleeding

4. Vasospasm

5. Hemodilution

Correct Answer: 2,3,4

Rationale 1: Hyponatremia is a more common complication.

Rationale 2: Hydrocephalus is a major complication that a nurse must anticipate following a ruptured intracranial aneurysm.

Rationale 3: Rebleeding is a major complication that a nurse must anticipate following a ruptured intracranial aneurysm.

Rationale 4: Vasospasm is a major complication that a nurse must anticipate following a ruptured intracranial aneurysm.

Rationale 5: Hemodilution is part of the treatment of cerebral vasospasm.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 22-4

Question 8

Type: MCSA

Which assessment data alerts the nurse to the fact that the patient is at risk for an embolic stroke?

1. Blood sugar of 110 mg

2. Right partial lung lobectomy 6 months ago

3. BP 108/68

4. History of atrial fibrillation

Correct Answer: 4

Rationale 1: Normal blood sugar is not a risk factor for embolic stroke.

Rationale 2: Partial lobectomy is not a risk factor for embolic stroke.

Rationale 3: Hypotension is not a risk factor for embolic stroke.

Rationale 4: Embolisms from cardiac sources are referred to as cardiogenic embolisms. The most common cause is atrial fibrillation, which accounts for almost 10% of all ischemic (embolic) strokes.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 22-1

Question 9

Type: MCSA

After being informed that their father has experienced a stroke that has affected a portion of his cerebrum, the patients family asks the nurse, What effect will aphasia have on his life? How should the nurse respond?

1. He will likely become depressed until he adjusts to the dysfunction.

2. Youll have to speak very loudly when you talk.

3. The way he communicates with you will change.

4. Perhaps you should learn about the different options for speech therapy.

Correct Answer: 3

Rationale 1: Depression may occur, but it is not related to the patients problems with verbal communication.

Rationale 2: Speaking loudly is more related to a hearing problem and would have little impact on the patients ability to communicate verbally.

Rationale 3: Aphasia is the term used to denote problems with verbal communication. Brocas area in the cerebrum regulates verbal expression, the ability to say words.

Rationale 4: Speech therapy may be an option for rehabilitation, but this response does not address the familys question.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 22-2

Question 10

Type: MCMA

The nurse is preparing an educational program focusing on various types of strokes. What types of strokes would the nurse include in a discussion of ischemic strokes?

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

Standard Text: Select all that apply.

1. Cardioembolic

2. Intracerebral hemorrhagic

3. Lacunar

4. Subarachnoid hemorrhagic

5. Atherosclerotic thrombotic

Correct Answer: 1,3,5

Rationale 1: Cardioembolic strokes are considered ischemic because they restrict or obstruct blood flow to a portion of the brain, resulting in cellular death.

Rationale 2: Intracerebral hemorrhagic strokes are a result of a severe blood loss from the vascular system of the brain.

Rationale 3: Lacunar strokes are considered ischemic because they restrict or obstruct blood flow to a portion of the brain, resulting in cellular death.

Rationale 4: Subarachnoid hemorrhagic strokes are a result of a severe blood loss from the vascular system of the brain.

Rationale 5: Atherosclerotic thrombotic strokes are considered ischemic because they restrict or obstruct blood flow to a portion of the brain, resulting in cellular death.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 22-1

Question 11

Type: MCMA

The nurse is reinforcing education regarding the risks of bypass procedures for a patient who has had an ischemic stroke. What risks should the nurse discuss?

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

Standard Text: Select all that apply.

1. Infection

2. Unstable blood pressure

3. Renal failure

4. Thrombotic stroke

5. Hemorrhage

Correct Answer: 1,2,4,5

Rationale 1: All surgical procedures, including bypass procedures, carry risks of infection and alteration in wound healing.

Rationale 2: Blood pressure instability can occur as a result of hemorrhage.

Rationale 3: Renal failure is not a general postprocedure risk after bypass surgery.

Rationale 4: Bypass procedures carry significant risk to the patient, such as stroke due to a clot in the graft or to a variety of other factors.

Rationale 5: Bypass procedures carry significant risk to the patient, including hemorrhage of the vessel.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 22-2

Question 12

Type: MCSA

A 27-year-old male arrives at the emergency department reporting a sudden severe-onset headache. Diagnostic studies confirm he is experiencing an intracerebral hemorrhage. The nurse recognizes which risk factor for this condition in the patients history?

1. The patient reports having a sprained ankle last week, for which he took ibuprofen.

2. The patient reports smoking a pack of cigarettes a day since he was 16 years old.

3. The patient is 27 years old.

4. The patient is male.

Correct Answer: 2

Rationale 1: Ibuprofen use is not a specific risk for intracerebral hemorrhage.

Rationale 2: Smoking is a risk factor for the development of aneurysms.

Rationale 3: Aneurysms are more common in those over 40.

Rationale 4: Aneurysms are more common in women.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 22-4

Question 13

Type: MCSA

An emergency department nurse is caring for a patient who has been diagnosed with an evolving ischemic stroke. The nurse anticipates preparing the patient and family for which initial medical intervention?

1. Craniotomy

2. Administration of t-PA (tissue plasminogen activator)

3. Full-body X-ray series

4. Watchful waiting over the next 24 hours

Correct Answer: 2

Rationale 1: A craniotomy evacuates a hematoma to relieve mass effect resulting from a hemorrhagic stroke.

Rationale 2: The administration of t-PA does not affect the infarcted, necrotic core, but may revitalize the penumbra and limit the extent of damage caused by ischemic stroke, thus minimizing the effects of the stroke.

Rationale 3: There is no indication that full-body X-rays are required.

Rationale 4: If an ischemic stroke is evolving, watchful waiting will allow it to progress.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 22-2

Question 14

Type: MCMA

The nurse is caring for a patient who experienced an ischemic stroke 8 hours ago. The nurse would expect an order to administer which medications designed to prevent further obstruction of vascular cerebral blood flow?

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

Standard Text: Select all that apply.

1. Intravenous dopamine

2. Intravenous mannitol

3. Subcutaneous insulin

4. Intravenous heparin

5. Subcutaneous low-molecular-weight heparin

Correct Answer: 4,5

Rationale 1: Intravenous dopamine is a vasopressor directed at stabilizing blood pressure.

Rationale 2: Intravenous mannitol is used to reduce intracranial pressure and brain mass.

Rationale 3: Subcutaneous insulin may be used to manage hyperglycemia resulting from the ineffective utilization of glucose.

Rationale 4: Anticoagulation with IV infusion of heparin for several days during the acute care management of a patient with ischemic stroke is common.

Rationale 5: Subcutaneous low-molecular-weight heparin (LMWH) can be used to manage a patient after ischemic stroke.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 22-2

Question 15

Type: MCMA

A diagnosis of cerebral salt wasting is made for a patient who recently experienced a subarachnoid hemorrhage (SAH) and is hyponatremic. The nurse recognizes the importance of which interventions?

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

Standard Text: Select all that apply.

1. Strictly monitoring intake and output

2. Monitoring hypertonic IV fluid therapy

3. Securing a serum sodium level every 6 hours

4. Restricting the patients fluids to 200 mL daily

5. Administering oral salt supplements

Correct Answer: 1,2,3,5

Rationale 1: It is important for the patients fluid intake and output to be carefully monitored.

Rationale 2: Poor management of hypertonic fluid intake can result in cardiac overload problems.

Rationale 3: It is very important for the patients serum sodium levels to be monitored frequently, every 6 hours if the patient is receiving hypertonic saline.

Rationale 4: Fluid restriction in this setting is absolutely contraindicated.

Rationale 5: Generally, the treatment for hyponatremia in SAH is hypertonic saline with oral salt supplements, if possible.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 22-4

Question 16

Type: MCMA

A patient is being treated for an aneurysmal subarachnoid hemorrhage (SAH) that occurred 10 days ago. The nurse recognizes that the

patient is at risk for decreased cerebral blood flow and is especially concerned when which assessments are made?

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

Standard Text: Select all that apply.

1. The patient seems unable to verbalize needs.

2. The patient has difficulty starting the flow of urine.

3. The patient reports a stiff neck.

4. The patient has a temperature of 101F.

5. The patient has unequal but reactive pupils.

Correct Answer: 1,3,4

Rationale 1: The peak incidence of vasospasm is 3 to 14 days from the incidence of SAH, although it may occur up to 21 days after the bleed occurs. Signs of vasospasm include aphasia.

Rationale 2: Signs of vasospasm do not include urinary hesitation.

Rationale 3: The peak incidence of vasospasm is 3 to 14 days from the incidence of SAH, although it may occur up to 21 days after the bleed occurs. Signs of vasospasm include neck stiffness.

Rationale 4: The peak incidence of vasospasm is 3 to 14 days from the incidence of SAH, although it may occur up to 21 days after the bleed occurs. Signs of vasospasm include fever.

Rationale 5: Signs of vasospasm do not include abnormal pupil size or reactivity.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 22-5

Question 17

Type: MCMA

The nurse is caring for a patient who is being treated for cerebral vasospasm with a medical treatment known as triple-H therapy. Which assessment data confirm that the treatment is currently effective?

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

Standard Text: Select all that apply.

1. Mean arterial pressure (MAP) 110 mmHg

2. Hematocrit 34%

3. Sodium of 125 mg/dL

4. Urine output 40 ml/hr

5. BP 170/96

Correct Answer: 1,2,3,5

Rationale 1: Mean arterial pressure (MAP) should be between 60 and 150 mmHg.

Rationale 2: Hematocrit should be greater than 30% to reflect good cerebral perfusion.

Rationale 3: Sodium level is not an assessment value used to monitor triple-H therapy.

Rationale 4: Urine output is not considered an assessment value for monitoring triple-H therapy.

Rationale 5: Triple-H therapy consists of hypertension, hemodilution, and hypervolemia. The goal of triple-H therapy is to increase cerebral perfusion pressure and CBF, therefore reducing the risk for further neurological deficits. Systolic blood pressure should be kept at no less than 160 mmHg.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 22-5

Question 18

Type: MCSA

The nurse is caring for a patient who is at risk for developing cerebral vasospasm. The nurse recognizes which order as inappropriate for this patient?

1. Discontinue IV fluids when tolerating fluids.

2. Monitor serum electrolytes daily.

3. Hold antihypertensive medications.

4. Monitor blood pressure hourly.

Correct Answer: 1

Rationale 1: Patients with subarachnoid hemorrhage are at significant risk for vasospasm. IV fluids should not be discontinued even if the patient has adequate oral intake.

Rationale 2: Monitoring serum electrolytes, especially sodium, is appropriate.

Rationale 3: Antihypertensive medications should not be administered without parameters for administration.

Rationale 4: Blood pressure should be monitored at least hourly.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 22-5

Question 19

Type: MCMA

A patient has infarct of the right anterior cerebral artery. The nurse would attribute which assessment findings to this condition?

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

Standard Text: Select all that apply.

1. The patient is incontinent of urine.

2. The patient cannot move the right leg.

3. The patient does not respond to light touch on the feet.

4. The patient cannot speak.

5. The patient has paralysis of the right arm.

Correct Answer: 1,3

Rationale 1: Incontinence is associated with infarct of the anterior cerebral artery.

Rationale 2: Anterior cerebral artery infarct would result in paresis of the left leg.

Rationale 3: Sensory deficits in the lower extremities are a finding associated with anterior cerebral artery infarct.

Rationale 4: Aphasia is not associated with infarction of the anterior cerebral artery.

Rationale 5: Paralysis of the upper extremities is not associated with infarct of the anterior cerebral artery.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-1

Question 20

Type: MCSA

A patients initial assessment revealed blood pressure 128/70, pulse 68, respirations 20, and pupils equal and reactive. The patient is awake and responding to verbal stimuli but demonstrating weakness on the left side. A medical diagnosis is presumptive stroke. Two hours later the patient is not awake but is easily aroused, has a blood pressure of 140/70, pulse 52, respirations 18, and the left pupil now reacts more slowly to light than the right pupil. Which complication is likely to have occurred?

1. Reperfusion injury

2. Normal stabilization poststroke

3. Increased intracranial pressure

4. Impending brain death

Correct Answer: 3

Rationale 1: Reperfusion injury results in further injury to already damaged tissue that is compromised and may be seen most often with thrombolytic therapy. There is no indication that this patient has had thrombolytic therapy.

Rationale 2: The most current assessment findings indicate that the patients condition is becoming more unstable.

Rationale 3: Rising systolic blood pressure, falling pulse, and a pupil that has become sluggish suggest increasing intracranial pressure (IICP) and requires notification of the health care provider.

Rationale 4: Brain death is diagnosed by a lack of brain waves and inability to maintain vital function.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 22-2

Question 21

Type: MCMA

A patient will have either endovascular coiling or neurosurgical clipping as treatment for an intracranial aneurysm. How would the nurse describe the benefits and risks of each form of treatment?

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

Standard Text: Select all that apply.

1. Surgery is the most reliable method of treating these aneurysms.

2. Coiling is only successful in very small aneurysms.

3. The decision of which approach to use is based on the patients preference.

4. Coiling is generally a less invasive option.

5. Coiling may require placement of a stent.

Correct Answer: 4,5

Rationale 1: Both surgery and coiling are acceptable methods of treating intracerebral aneurysms, and each has specific indications for use.

Rationale 2: The size of the aneurysm is not as important as its configuration and the configuration of vessels in the immediate vicinity.

Rationale 3: The decision of which approach to use is based largely on the angiographic features of the aneurysm.

Rationale 4: Coiling is a nonsurgical approach and is less invasive than craniotomy.

Rationale 5: If the aneurysm is broad based, a stent may be placed in the parent artery to act as a scaffold for the coils.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 22-4

Question 22

Type: MCSA

A patient is diagnosed with a lacunar stroke. The patients daughter says, If this is a stroke in a small artery, why is my dads movement so affected? Which nursing response is indicated?

1. Lacunar strokes occur in large arteries, not small ones.

2. Lacunar strokes look small on the scans, but they often happen in areas where lots of motor and sensory tracts are located.

3. Most of the time with lacunar strokes, we see more sensory effects than those your dad has experienced.

4. Lacunar strokes occur in small arteries, but the damage seen on scans is massive.

Correct Answer: 2

Rationale 1: Lacunar strokes are also known as small artery occlusive disease.

Rationale 2: Lacunar strokes often occur in areas that are rich in motor and sensory tracts. This results in a small area of damage causing a large effect.

Rationale 3: Lacunar syndromes can be subdivided into pure motor, pure sensory, sensorimotor, and ataxic hemiparesis.

Rationale 4: Lacunar strokes look small on imaging.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 22-1

Question 23

Type: MCSA

The nurse is presenting a community health program regarding stroke. The nurse emphasizes the importance of early transport to the emergency department. What is the primary rationale for this recommendation?

1. Prompt treatment can save cells in the penumbra.

2. Early reperfusion expands the penumbra.

3. Early intervention can decrease autoregulation.

4. Early treatment eliminates the possibility of reperfusion injury.

Correct Answer: 1

Rationale 1: The penumbra is an area of cells surrounding the necrotic core of brain tissue present in a stroke. These penumbra cells can be salvaged if reperfusion is prompt.

Rationale 2: Early reperfusion decreases the penumbra.

Rationale 3: Autoregulation is a protective physiological response. The goal is to increase autoregulation.

Rationale 4: Reperfusion injury is not reduced by early treatment.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 22-3

Question 24

Type: MCSA

The patient with assessment findings of stroke has a normal CT scan upon admission to the emergency department. How should the nurse evaluate this information?

1. Intracranial aneurysm is a more likely diagnosis.

2. The patient must have a psychosomatic illness.

3. A second CT done later may show damage.

4. The patient should have an electroencephalogram.

Correct Answer: 3

Rationale 1: There is no evidence that this is true.

Rationale 2: The patient likely has a physiological illness.

Rationale 3: Initial CT scans often do not show infarcted tissue even though an occluded artery is present.

Rationale 4: Electroencephalograms are useful in detecting abnormal brain activity such as seizure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 22-2

Question 25

Type: FIB

A patient experienced onset of weakness, left-sided facial drooping, and difficulty talking 2 hours before presenting in the emergency department. The patient has been in the ED for 30 minutes, and the nurse is aware that t-PA treatment for stroke must be administered within the next _______ hours to be effective.

Standard Text:

Correct Answer: 2

Rationale : The t-PA must be administered within 4.5 hours of the onset of symptoms. This patient waited 2 hours before coming to the ED and has been in the ED for 30 minutes, for a total of 2.5 hours. 4.5-2.5 = 2 hours

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 22-2

Question 26

Type: MCSA

A patient is scheduled for a lumbar puncture to assess for subarachnoid hemorrhage. The nurse should check to see if which test has been performed prior to the procedure?

1. Serum glucose

2. BUN

3. Chest X-ray

4. CT scan of the head

Correct Answer: 4

Rationale 1: While many laboratory tests will probably be done on this patient, serum glucose is not the most critical.

Rationale 2: While many laboratory tests will probably be done on this patient, BUN is not the most critical.

Rationale 3: While a chest X-ray may be done on this patient, it is not the most critical test.

Rationale 4: Lumbar puncture should not be performed until the presence of a space-occupying lesion is ruled out.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 22-4

Question 27

Type: FIB

A patient has been admitted with stroke-like symptoms. The nurse would report a serum potassium level of less than _____mEq/L as below the desired level.

Standard Text:

Correct Answer: 3.5

Rationale : The goal for potassium is between 3.5 and 5.3 mEq/L.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 22-2

Question 28

Type: MCSA

After a stroke, a patient was left with painful feet and hands. The physician diagnoses central pain syndrome. Which home management technique should the nurse teach this patient?

1. Keep your feet and hands warm.

2. Walking will improve your comfort.

3. Taking an ACE inhibitor will decrease the pain.

4. Ice massage may help your pain.

Correct Answer: 1

Rationale 1: Temperature change, especially cold temperature, makes the pain worse.

Rationale 2: Movement often makes pain worse.

Rationale 3: ACE inhibitors are prescribed for blood pressure control.

Rationale 4: Cold temperatures often make the pain more severe.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 22-2

Question 29

Type: MCSA

A patient is admitted to the emergency department after complaining of a headache and having a seizure. On CT examination the patient is assigned a Fisher score of 1. How does the nurse evaluate this information?

1. There is no blood detected on the CT scan.

2. The CT scan shows no ischemia.

3. The CT scan must be repeated with contrast.

4. The aneurysm can be treated with coiling.

Correct Answer: 1

Rationale 1: The Fisher grading scale is based on the amount of blood on the CT scan.

Rationale 2: The Fisher scale is not associated with ischemia.

Rationale 3: The Fisher scan does not determine the quality of the CT scan.

Rationale 4: The Fisher grading scale does not address the choice of treatment.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 22-4

Question 30

Type: FIB

The nurse is monitoring a patient who has had a subarachnoid bleed. The nurse plans care based on the knowledge that the risk for cerebral vasospasm is highest in Fisher grade _______ aneurysms.

Standard Text:

Correct Answer: 3

Rationale : Fisher grade 3 aneurysms have a localized clot or a layer of blood greater than 1 mm thick. This configuration makes cerebral vasospasm more likely due to irritation of tissues.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 22-4

Question 31

Type: MCSA

Results of diagnostic procedures reveal that a patients cerebral arteriovenous malformation (AVM) is Spetzler-Martin grade 1. The nurse anticipates which most common treatment for this patient?

1. Surgical resection

2. Endovascular coiling

3. Radiosurgery

4. Watchful waiting

Correct Answer: 1

Rationale 1: If there is no condition that would preclude surgery, patients with Spetzler-Martin grade 1 or 2 AVM are generally treated with surgical resection.

Rationale 2: Endovascular coiling may be indicated, but this is not the most common treatment approach to this AVM.

Rationale 3: Gamma knife radiosurgery is an option, but this treatment is generally reserved for surgically inaccessible lesions.

Rationale 4: Conservative treatment or watchful waiting is reserved for higher-grade AVM because treatment is felt to be unsafe.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 22-4

Question 32

Type: MCMA

Diagnostic testing has revealed that the patient has an arteriovenous malformation (AVM). Surgical treatment is scheduled for tomorrow. Which critical assessment findings should the nurse report to the surgeon?

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

Standard Text: Select all that apply.

1. Headache unchanged since admission

2. Seizure

3. A period of sudden clarity after previously disturbed thought processing

4. Increased difficulty in talking

5. Sudden decrease in level of consciousness

Correct Answer: 2,4,5

Rationale 1: Headache is a common finding in AVM and may be the reason the patient presented for treatment. The headache will likely continue until the AVM is treated.

Rationale 2: Because AVMs often affect cortical brain, seizures are common.

Rationale 3: There is no indication that a period of lucidity will change the patients treatment plan. The AVM poses a lifelong risk of rupture and should be treated.

Rationale 4: Increased difficulty talking may indicate that the AVM is leaking.

Rationale 5: A sudden decrease in LOC indicates possible rupture of the AVM, which is an emergency.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 22-4

Question 33

Type: MCSA

A patient with a family history of cavernous malformation presents to the emergency department following a seizure. The nurse anticipates which diagnostic testing?

1. Angiography

2. CT scan

3. Skull series X-ray

4. MRI scan

Correct Answer: 4

Rationale 1: Cavernous malformations are low-flow lesions, and angiography is not diagnostic.

Rationale 2: A CT scan is not the most diagnostic tool available.

Rationale 3: Skull series X-ray is not the most diagnostic tool available.

Rationale 4: MRI scanning is the diagnostic tool of choice when cavernous malformation is suspected.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 22-4

Question 34

Type: MCSA

The nurse is planning care for a patient undergoing diagnostic evaluation for presence of an intracranial bleed. Which nursing diagnosis (NDX) would the nurse set as the first priority?

1. Impaired Verbal Communication

2. Potential for Aspiration

3. Risk for Altered Cerebral Tissue Perfusion

4. Altered Coping

Correct Answer: 3

Rationale 1: The patient may have impairment of verbal communication, so this is an appropriate NDX but is not the priority.

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