Cerebrovascular Accident
MULTIPLE CHOICE
1. A post-CVA patient who has weakness on the right side and impaired reasoning has had the CVA in the:
1. left hemisphere of the cerebrum.
2. right hemisphere of the cerebrum.
3. left cerebellum.
4. right cerebellum.
ANS: 1
Impaired motor strength on the right side in conjunction with impaired reasoning indicates a lesion in the left hemisphere of the cerebrum. The cerebellum controls balance and is not contralateral.
PTS: 1 DIF: Cognitive Level: Analysis REF: 460
OBJ: 3 TOP: Symptoms of CVA
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
2. The nurse counsels that the patient at the greatest risk for a CVA is a:
1. 20-year-old obese Latin woman on birth control pills.
2. 40-year-old athletic white man with a family history of CVA.
3. 60-year-old Asian woman who smokes occasionally.
4. 65-year-old African-American man with hypertension.
ANS: 4
Older African-Americans have a higher incidence of CVA than occasional smokers, young, or athletic persons. Hypertension increases the risk.
PTS: 1 DIF: Cognitive Level: Analysis REF: 462
OBJ: 1 TOP: CVA Risk Factors
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance
3. A patient experienced a period of momentary confusion, dizziness, and slurred speech, but recovered in 2 hours. The most helpful assessment in the diagnosis of this episode would be:
1. patient complaint of nausea.
2. blood pressure of 140/90.
3. patient complaint of headache.
4. auscultation of a bruit over the carotid.
ANS: 4
A carotid bruit is evidence of a narrowing in that vessel, a symptom of a possible CVA or TIA. BP of 140/90 is within normal limits. Headache and nausea alone are too common to be definitive.
PTS: 1 DIF: Cognitive Level: Application REF: 464
OBJ: 2 TOP: TIA Diagnosis
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance
4. The patient who experienced a TIA is placed on warfarin (Coumadin) and has laboratory reports reflecting a therapeutic range for that drug, which are:
1. prothrombin time (PT), 35 seconds; control (normal), 20 seconds; INR, 2.
2. partial thromboplastin time (PTT), 30 seconds; control (normal), 30 seconds.
3. prothrombin time (PT), 45 seconds; control (normal), 20 seconds; INR, 4.
4. partial thromboplastin time (PTT), 52 seconds; control (normal), 30 seconds.
ANS: 1
Prothrombin time of 1.5 to 2 times normal is the therapeutic goal for Coumadin. The INR for Coumadin therapy is 2 to 3. Partial thromboplastin time is the test for heparin.
PTS: 1 DIF: Cognitive Level: Analysis
REF: 465, Drug Therapy table OBJ: 3
TOP: Anticoagulant Therapy KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
5. The nurse updates the teaching plan for a post-TIA patient to include the provision for:
1. a daily aspirin dose.
2. long rest periods daily.
3. reduction of fluid intake to 800 mL/day.
4. high-carbohydrate diet.
ANS: 1
Daily aspirin reduces platelet aggregation and may prevent another attack. Reduction of fluid and long rest periods encourage clot formation.
PTS: 1 DIF: Cognitive Level: Application REF: 464
OBJ: 1 TOP: Post-TIA Teaching
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance
6. The patient recovering from a CVA asks the purpose of the Coumadin (warfarin). The best response by the nurse is that Coumadin:
1. dissolves the clot.
2. prevents formation of new clots.
3. dilates the vessels to improve blood flow.
4. suppresses the formation of platelets.
ANS: 2
Coumadin and heparin prevent more clots rather than dissolving them. Coumadin has no effect on vasodilation or blood cell production.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 464
OBJ: 3 TOP: Coumadin Therapy
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
7. The nurse explains that a patient who has been determined to have had a complete stroke as a result of a ruptured vessel in the left hemisphere would be classified as:
1. ischemic, embolic.
2. hemorrhagic, subarachnoid.
3. hemorrhagic, intracerebral.
4. ischemic, thrombotic.
ANS: 3
A ruptured vessel in a hemisphere is an intracerebral hemorrhagic CVA. It is not in the subarachnoid space. Ischemic CVAs are due to occluded vessels.
PTS: 1 DIF: Cognitive Level: Analysis REF: 466
OBJ: 2 TOP: CVA Classification
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
8. Immediately after a CVA, a major nursing priority is ensuring:
1. preservation of motor function.
2. airway maintenance.
3. adequate hydration.
4. control of elimination.
ANS: 2
Adequate oxygenation prevents hypoxemia, which can extend and worsen the CVA.
PTS: 1 DIF: Cognitive Level: Application REF: 470
OBJ: 6 TOP: Nursing Care of Acute CVA
KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
9. The nurse recognizes that the acute phase of a CVA has ended when:
1. 48 hours has passed from onset.
2. the patient begins to respond verbally.
3. the blood pressure drops.
4. vital signs and neurologic signs stabilize.
ANS: 4
When the vital and neurologic signs stabilize, the acute phase has ended. Verbal response, lower BP, and passage of time, without other signs, are not adequate evidence.
PTS: 1 DIF: Cognitive Level: Analysis REF: 469
OBJ: 6 TOP: Acute Phase of CVA
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
10. A patient in the acute phase of a stroke who has been speaking distinctly begins to speak indistinctly and only with great effort, but is coherent. The nurse assesses:
1. stroke in evolution with dysarthria.
2. lacunar stroke with fluent aphasia.
3. complete stroke with global aphasia.
4. stroke in evolution with dyspraxia.
ANS: 1
As symptoms worsen, the CVA is still evolving. Speech that is coherent but difficult is dysarthria rather than any type of aphasia. Dyspraxia is a motor impairment, not speech impairment.
PTS: 1 DIF: Cognitive Level: Analysis REF: 466
OBJ: 4 TOP: CVA Deficits
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance
11. Several days after a CVA, the patient’s family asks the nurse if tissue plasminogen activator (tPA) is a drug therapy option now. The nurse’s response is based on the knowledge that this drug must be used within:
1. 3 hours of onset of symptoms.
2. 5 hours of onset of symptoms.
3. 10 hours of onset of symptoms.
4. 24 hours of onset of symptoms.
ANS: 1
tPA is to be given within 3 hours of onset of symptoms per FDA guidelines.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 470
OBJ: 3 TOP: CVA Medication Implementation
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
12. The nurse explains that a lumbar puncture is most helpful as a diagnostic tool for a new stroke patient, because it can help determine if the stroke:
1. is lacunar.
2. is hemorrhagic or embolic.
3. is complete or in evolution.
4. will result in paralysis.
ANS: 2
Blood in the spinal fluid indicates hemorrhagic stroke and will help direct medical protocol in subsequent treatment.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 469
OBJ: 5 TOP: CVA Diagnostic Tests
KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance
13. A patient who has suffered a hemorrhagic stroke is placed on a protocol of 60 mg nimodipine (calcium channel blocker) every 4 hours. The patient’s pulse is 82 prior to the administration of the prescribed dose. The nurse should:
1. give the full dose as prescribed, without further assessment.
2. omit the dose, recording the pulse rate as the rationale.
3. delay the dose until the pulse is below 60.
4. give half of the prescribed dose (30 mg).
ANS: 1
The dose should be given; it would be held only if the pulse is below 60. Assessments should be made regarding BP, urine output, and edema.
PTS: 1 DIF: Cognitive Level: Application
REF: 465, Drug Therapy table OBJ: 3
TOP: CVA Medical Protocol KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
14. During the acute CVA phase, there is a risk for falls related to paralysis. The intervention that best protects the patient from injury is:
1. keep the bed in a high position for ease of nursing care.
2. keep the side rails up, according to agency policy.
3. assess vision deficit related to ptosis.
4. monitor the condition every 2 hours.
ANS: 2
Rails keep patients in bed. The bed should be low, monitoring the patient should be more frequent than every 2 hours, and visual assessment is not directly related to fall prevention.
PTS: 1 DIF: Cognitive Level: Application REF: 476
OBJ: 7 TOP: Acute Care: Fall Prevention
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment
15. Pneumonia is the most frequent cause of death after a stroke. The intervention that would be contraindicated in the acute care of a patient with a hemorrhagic CVA is to:
1. thicken liquids to ease swallowing and prevent aspiration.
2. change position every 30 to 60 minutes.
3. maintain adequate fluid intake, orally or IV.
4. encourage forceful coughing to stimulate deep breathing.
ANS: 4
Forceful coughing is contraindicated for a hemorrhagic CVA patient, because it may cause ICP.
PTS: 1 DIF: Cognitive Level: Application REF: 476
OBJ: 7 TOP: Prevention of Pneumonia
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
16. The assessments that indicate a fluid volume excess in a patient in the acute phase of a CVA is:
1. decreased blood pressure.
2. weak pulse.
3. adventitious breath sounds.
4. high specific gravity of urine.
ANS: 3
Crackles in the lung fields are a major indicator of fluid excess. The pulse and BP are elevated in fluid excess. Urine specific gravity is low in fluid excess.
PTS: 1 DIF: Cognitive Level: Analysis REF: 477
OBJ: 7 TOP: Fluid Excess
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
17. The nurse adds to the nursing care plan the intervention that will help preserve joint mobility in the acute phase of a CVA, which is:
1. pull the limbs on the affected side into a functional position.
2. aggressive full range of motion for all extremities.
3. support affected points in good functional alignment.
4. exercise the limbs every 8 hours.
ANS: 3
Limbs maintained in a functional anatomical position and gently exercised (never pulled) into an acceptable range of motion several times a shift will maintain optimal mobility.
PTS: 1 DIF: Cognitive Level: Application REF: 479
OBJ: 7 TOP: Preserving Joint Mobility
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
18. The postembolic CVA patient in the acute phase has an order for 400 units of heparin per hour IV. The heparin is in a solution of 5000 units/100 mL NS. The nurse should set the electronic IV monitor at how many milliliters per hour?
1. 6
2. 8
3. 10
4. 16
ANS: 2
Regardless of the method of calculation, there are 50 units of heparin in each milliliter of the solution; 8 mL/hour delivers 400 units. (5000 units divided by 100 mL NS = 50 units/mL. 400 units divided by 50 units/mL = 8 mL.)
PTS: 1 DIF: Cognitive Level: Application
REF: N/A review for application of prior knowledge OBJ: 7
TOP: Heparin Therapy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
19. The nurse assesses that the CVA patient is in transition to the rehabilitation phase when:
1. the blood pressure has been within normal limits for 24 hours.
2. the patient makes positive statements about his condition.
3. there are no further neurologic deficits observed.
4. there are successful attempts at independent function.
ANS: 3
When no further deficits are noted and all vital signs have stabilized, the patient is considered to be in the rehabilitation phase. Positive statements and attempts at independence are not sufficient.
PTS: 1 DIF: Cognitive Level: Analysis REF: 480
OBJ: 7 TOP: Rehabilitation Phase
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
20. In the rehabilitation phase of a CVA, patients with homonymous hemianopsia need to have their environment arranged so that persons approaching and important items are available on:
1. the unaffected side.
2. the affected side.
3. the direct front.
4. either side.
ANS: 2
Making the patient scan the affected side helps stimulate the return of normal function in the rehabilitation phase.
PTS: 1 DIF: Cognitive Level: Application REF: 469
OBJ: 7 TOP: Hemianopsia
KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
21. The nurse, using the nursing diagnosis “Imbalanced nutrition related to dysphagia,” with the goal of adequate nutrition, would select the appropriate outcome criterion as:
1. offers variety of food groups.
2. eats half of all meals offered.
3. maintains body weight of 150 to 155 pounds.
4. eats all meals independently.
ANS: 3
The maintenance of a desired weight is indicative of adequate nutrition. Eating a portion of meal or eating independently does not adequately measure the extent the goal was met. Offering a variety of foods is a nursing or dietary function, not an outcome.
PTS: 1 DIF: Cognitive Level: Analysis REF: 477
OBJ: 8 TOP: Rehabilitation: Nutrition
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance
22. The nurse selects the most effective intervention for best support of regular bowel elimination and prevention of constipation, which is:
1. limit fluid intake to 32 to 50 ounces/day to compact stool.
2. small soapsuds enema every other day to cleanse bowel.
3. daily stool softeners, with consistent time to attempt elimination.
4. a strong laxative on a daily basis to encourage evacuation.
ANS: 3
Daily stool softeners rather than daily laxatives or frequent enemas help restore regularity and bowel tone.
PTS: 1 DIF: Cognitive Level: Analysis REF: 479
OBJ: 7 TOP: Bowel Elimination
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance
23. The post-CVA patient in the rehabilitation phase accidentally knocks the adapted plate from the table and bursts into tears after failing to feed himself. The nurse’s best response would be:
1. “Don’t cry. You’ll be mastering eating in no time.”
2. “I don’t believe crying will help. Let’s try drinking from a special cup.”
3. “Bless your heart! Let me get a new meal and feed you.”
4. “Learning new skills is hard. Let’s see what may have caused the trouble.”
ANS: 4
Recognizing effort and showing support are the best approaches to depression and frustration. “Babying” the patient and admonitions against crying add to the problem.
PTS: 1 DIF: Cognitive Level: Analysis REF: 481-482
OBJ: 7 TOP: Rehabilitation: Coping
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
24. The instruction that is most helpful in teaching the rehabilitating CVA patient and his family about altered sensation is to:
1. make frequent assessments for signs of pressure or injury.
2. use the affected side in supporting the patient in ambulation and transfer to stimulate better sensation.
3. apply ice packs to the affected limbs to encourage return of sensation.
4. apply a heating pad to the affected limbs to increase circulation.
ANS: 1
Frequent assessment will allow early detection. Use of hot or cold applications and using the affected limbs in transfer or ambulation may cause injury.
PTS: 1 DIF: Cognitive Level: Application REF: 484
OBJ: 7 TOP: Altered Sensation
KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment
25. The nurse encourages the posthospital option that would provide the most comprehensive assistance to a recovering post-CVA, which is:
1. transfer to a rehabilitation center.
2. discharge to home with scheduled visits from home health nurses.
3. discharge to home with scheduled visits from a physical therapist.
4. discharge to home with scheduled visits from an occupational therapist.
ANS: 1
A rehabilitation center with all modalities of support (physical therapy, occupational therapy, speech therapy, and simulated home environments) is obviously the best option.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 484
OBJ: 9 TOP: Postdischarge Planning
KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment
26. The nurse explains that a lacunar stroke differs from an ischemic CVA in that a lacunar CVA (select all that apply):
1. causes a great deal of pain.
2. alters the personality.
3. affects small arteries.
4. nearly always results in blindness.
5. produces larger amount of neurologic damage.
ANS: 3
The lacunar CVA only affects small arteries and produces a small amount of neurologic damage.
PTS: 1 DIF: Cognitive Level: Analysis REF: 467
OBJ: 4 TOP: Lacunar CVA
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1. The nurse suspects a TIA when the assessment of a patient reveals transitory (select all that apply):
1. incontinence.
2. dysphagia.
3. ptosis.
4. tinnitus.
5. dysarthria.
ANS: 2, 3, 4, 5
All but transitory incontinence are classic symptoms of TIA. These deficits usually disappear without permanent disability in about 24 hours.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 462-463
OBJ: 1 TOP: Symptoms of TIA
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
2. The nurse explains that the purpose of a stent in the carotid artery of a person with a TIA is to (select all that apply):
1. capture circulating clots.
2. help with subsequent angioplasties.
3. keep the artery open.
4. prevent hemorrhage.
5. measure pressure in the artery.
ANS: 3
The only thing that the stent does is keep the artery open.
PTS: 1 DIF: Cognitive Level: Analysis REF: 466
OBJ: 6 TOP: Use of Stent KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
3. The nurse is supportive of the frustrated patient with expressive aphasia because the condition is characterized by (select all that apply):
1. speech that sounds normal, but makes no sense.
2. total inability to communicate.
3. difficulty understanding the written and spoken word.
4. stuttering and spitting.
5. difficulty initiating speech.
ANS: 5
Expressive aphasia makes it difficult for the patient to initiate speech.
PTS: 1 DIF: Cognitive Level: Analysis REF: 468
OBJ: 3 TOP: Expressive Aphasia
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
COMPLETION
1. The nurse checks the O2 in the circulating volume for adequate concentration to support the brain’s need of ____________________% of the oxygen supply of the body.
ANS: 20%
PTS: 1 DIF: Cognitive Level: Application REF: 461
OBJ: 6 TOP: O2 Needs of the Brain
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
