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 Question 11 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 Question 12 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. Question 13 A patient is receiving tissue plasminogen activator (tPA) for the treatment of an ischemic stroke. Which nursing interventions are indicated? 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. Question 14 Which nursing interventions are indicated when providing care for a patient recovering from right carotid endarterectomy? 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. Question 15 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 Question 16 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 Question 17 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. Question 18 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 Question 19 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. Question 20 A patient had a stroke which resulted in Broca’s aphasia. What instructions should the nurse provide when teaching the family how to communicate with this patient? 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 patient’s answers and finish questions and sentences. 5. Give the patient time to search for words.