Nur 242 exam 4
Which intervention would the disaster management team nurse perform for the survivors of an explosion who developed heat stroke? - ANSWER-Apply ice packs on the client's scalp
Which level of care is the nurse providing when preparing to discharge a client who is learning to walk again after a stroke to a rehabilitation center? - ANSWER-tertiary care
Which action by the emergency department nurse is the priority for a client with heat stroke? - ANSWER-Assess the airway and breathing
A client who sustains a stroke has a loss of proprioception and fine touch. Which artery would the nurse suspect is damaged? - ANSWER-Anterior cerebral
A client has a brain attack (stroke) that involves the right cerebral cortex and cranial nerves. Which areas of paralysis would the nurse expect to find upon assessment?Select all that apply. One, some, or all responses may be correct. - ANSWER-Left leg Left arm Left side of face
Initially after a stroke, a client's pupils are equal and reactive to light. Later, the nurse assesses that the right pupil is reacting more slowly than the left and that the systolic blood pressure is rising. Which complication would the nurse plan to address? - ANSWER-Increased intracranial pressure
The registered nurse (RN) is caring for a client who is currently hospitalized for a stroke.Which professional management strategy will be most effective for the RN to improve the safety and quality of client care? - ANSWER-Delegation
The client taking intravenous coagulant medications for a bleeding disorder suddenly develops an embolic stroke as a result of medication overdose. Which actions by the hospital management does the Leapfrog Group suggest? Select all that apply. One, some, or all responses may be correct. - ANSWER-Apologize to the client and family.Waive all costs directly related to the adverse effect.Report the adverse event to The Joint Commission.
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The nurse is planning care for an immobilized client who had a stroke with right-sided hemiparesis. Which activity would the nurse include in the plan of care? - ANSWER- Assist the client to perform range-of-motion (ROM) exercises every 1 to 2 hours
Which is the priority nursing action for a client admitted to the hospital in a coma after having a stroke? - ANSWER-Maintain an open airway.
Which position would the nurse plan to use for the client who is having a hypertensive crisis and evolving stroke? - ANSWER-Side-lying
Which nursing action is essential when a client experiences hemianopsia as the result of a left ischemic stroke? - ANSWER-Place objects within the visual field
Which action will the nurse complete when preparing a stroke client for cerebral imaging with iodine-based contrast dye? - ANSWER-Ensure a recent creatinine level has been assessed.
Which behaviors would the nurse include when teaching a family what to expect from a client who experienced a stroke on the left side of the brain? Select all that apply. One, some, or all responses may be correct. - ANSWER-Slow performance and caution Impaired speech/language aphasias Awareness of deficits with depression and anxiety
When a client has difficulty swallowing after a stroke, which action by the nurse would be most important in preventing pneumonia? - ANSWER-Having suction available during meals
A client has had a recent brain attack (cerebrovascular accident/stroke). Which preventative would the nurse anticipate will be prescribed daily to avoid straining due to constipation? - ANSWER-Stool softener
Initially after a stroke, the client's pupils are equal and reactive to light. Four hours later, the nurse identifies that one pupil reacts more slowly than the other and the client's systolic blood pressure is increasing. For which condition would the nurse prepare to intervene? - ANSWER-Increased intracranial pressure
The nurse observes dorsiflexion of the big toe and fanning of other toes when the lateral side of a client's foot is stroked. Which finding would the nurse document? - ANSWER- Exhibits a positive Babinski sign
The nurse is caring for a client who had a stroke and who has varying moods ranging from anger to depression to concern about the aphasia, hemiparesis, and the gavage feedings. Which behavior indicates the client's acceptance of physical limitations? - ANSWER-Performs tube feedings without assistance
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A client has dysarthria after a stroke. Which goal would the nurse include in the plan of care to address this problem? - ANSWER-Effective communication
Which reflex is the nurse testing when using a dull object to stroke from the lateral sole of a client's foot upward to the great toe? - ANSWER-Babinski
A client admitted to the hospital with the diagnosis of a right-sided "brain attack" (stroke) is right-handed. Which task will be most difficult for this client? - ANSWER-Dressing every morning
The nurse assessed a client who experienced a recent brain attack (stroke) and has a residual right-sided hemiplegia. Which rationale explains the importance of the nurse identifying mobility restrictions or neuromuscular abnormalities when assessing this client? - ANSWER-Shortening and eventual atrophy of the affected muscles will occur
Which condition of a client with hemorrhagic stroke resulting from a motor bike accident requires immediate attention? - ANSWER-Body temperature of 81.2°F
In which order would the nurse caring for a client suffering from heatstroke provide emergency interventions? - ANSWER-Ensure a patent airway.Remove the client from the hot environment.Remove the client's clothing Pour or spray cold water on the client's body and scalp.Fan the client with newspapers or whatever is available.Place ice in cloth or bags and position the packs on the client's scalp Emergency care should be provided to the client with heatstroke to restore thermoregulation. First the nurse would ensure a patent airway. Then the nurse would remove the client from the hot environment into air conditioning or shade and remove his or her clothing. Then the nurse would pour or spray cold water on the client's body and scalp. The client should be fanned with newspapers or whatever is available. This should be followed by placing ice in cloth or bags and positioning the packs on the client's scalp.
Which priority interventions would the nurse provide to the client hospitalized with heatstroke, a body temperature of 106°F, and skin that is hot and dry? Select all that apply. One, some, or all responses may be correct - ANSWER-Remove the client's clothing.Immerse the client in cold water
Which nursing intervention is the priority for a client with stroke who is transitioned from the emergency department (ED) to other settings? - ANSWER-Assessing the level of consciousnes
Which client condition requires a medium priority of care according to the National Institutes of Health Stroke Scale (NIHSS) score? - ANSWER-Facial palsy score of 1
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