CVA (STROKE) PRACTICE QUESTIONS AND
ANSWERS 2022 LATEST UPDATE
A 78-year-old client is admitted to the emergency department with numbness and
weak- ness of the left arm and slurred speech. Which nursing intervention
...
CVA (STROKE) PRACTICE QUESTIONS AND
ANSWERS 2022 LATEST UPDATE
A 78-year-old client is admitted to the emergency department with numbness and
weak- ness of the left arm and slurred speech. Which nursing intervention is priority?
1. Prepare to administer recombinant tissue plasminogen activator (rt-PA).
2. Discuss the precipitating factors that caused the symptoms.
3. Schedule for a STAT computed tomography (CT) scan of head.
4. Notify the speech pathologist for an emergency consult. - ANS-1) The drug rt-PA
may be administered, but a cerebrovascular accident (CVA) must be veri- fied by
diagnostic tests prior to administering it. rt-PA helps dissolve a blood clot, and it may
be administered if an ischemic CVA is verified, rt-PA would not be given if the client
were experiencing a hemorrhagic stroke.
2) Teaching is important to help prevent another CVA, but it is not the priority
intervention on admission to the emergency department. Slurred speech indicates
problems that may interfere with teaching.
3)* A CT scan will determine if the client is having a stroke or has a brain tumor or
another neurological disorder. If a CVA is diagnosed, the CT scan can determine if it
is a hemorrhagic or ischemic accident and guide treatment.
4) The client may be referred for speech deficits and/or swallowing difficulty, but
referrals are not priority in the emergency department.
TEST-TAKING HINT: When "priority" is used in the stem, all answer options may be
appropriate for the client situation, but only one answer is priority. The client must
have a documented diagnosis before treatment is started.
The nurse is assessing a client experiencing motor loss as a result of a left-sided
cere- brovascular accident (CVA). Which clinical manifestations would the nurse
document?
1. Hemiparesis of the client's left arm and apraxia.
2. Paralysis of the right side of the body and ataxia.
3. Homonymous hemianopsia and diplopia.
4. Impulsive behavior and hostility toward family. - ANS-1) A left-sided CVA will
result in right-sided motor deficits; hemiparesis is weakness of one half of the body,
not just the upper extremity. Apraxia, the inability to perform a previously learned
task, is a communication loss, not a motor loss.
2)*The most common motor dysfunction of a CVA is paralysis of one side of the
body, hemiplegia; in this case with a left-sided CVA, the paralysis would affect the
right side. Ataxia is an impaired ability to coordi- nate movement.
3) Homonymous hemianopsia (loss of half of the visual field of each eye) and
diplopia (double vision) are visual field deficits that a client with a CVA may
experience, but they are not motor losses.
4) Personality disorders occur in clients with a right-sided CVA and are cognitive
deficits; hostility is an emotional deficit.
TEST-TAKING HINT: Be sure to always notice adjectives describing something. In
this case, "left-sided" describes the type of CVA. Also be sure to identify exactly what
the question is asking—in this case, about "motor loss," which will help rule out many
of the possible answers.
Which client would the nurse identify as being most at risk for experiencing a CVA?
1. A 55-year-old African American male.
2. An 84-year-old Japanese female.
3. A 67-year-old Caucasian male.
4. A 39-year-old pregnant female. - ANS-1)* African Americans have twice the rate
of CVAs as Caucasians and men have a higher incidence than women; African
Americans suffer more extensive damage from a CVA than do people of other
cultural groups.
2) Females are less likely to have a CVA than males, but advanced age does
increase the risk for CVA. The Oriental population has a lower risk, possibly as a
result of their relatively high intake of omega-3 fatty acids, antioxidants found in fish.
3) Caucasians have a lower risk of CVA than do African Americans, Hispanics, and
Native Pacific Islanders.
4) Pregnancy is a minimal risk for having a CVA.
TEST-TAKING HINT: Note the age of the client if this information is given, but take
this infor- mation in context with the additional informa- tion provided in the questionand-answer possibilities. The 84-year-old may appear to be the best answer but not
if the client is a female and Oriental, which rules out this answer for the client most at
risk.
The client diagnosed with a right-sided cerebrovascular accident is admitted to the
reha- bilitation unit. Which interventions should be included in the nursing care plan?
Select all that apply.
1. Position the client to prevent shoulder adduction.
2. Turn and reposition the client every shift.
3. Encourage the client to move the affected side.
4. Perform quadriceps exercises three (3) times a day.
5. Instruct the client to hold the fingers in a fist. - ANS-1)* Placing a small pillow
under the shoulder will prevent the shoulder from adducting toward the chest and
developing a contracture.
2) The client should be repositioned at least every two (2) hours to prevent
contractures, pneumonia, skin breakdown, and other complications of immobility.
3)* The client should not ignore the paralyzed side, and the nurse must encourage
the client to move it as much as possible; a writ- ten schedule may assist the client in
exercising.
4) These exercises are recommended, but they must be done at least five (5) times
a day for ten (10) minutes to help strengthen the muscles for walking.
5) The fingers are positioned so that they are barely flexed to help prevent
contracture of the hand.
TEST-TAKING HINT: Be sure to look at the intervals of time for any intervention;
note that "every shift" and "three times a day" are not appropriate time intervals for
this client.
The nurse is planning care for a client experiencing agnosia secondary to a
cerebrovas- cular accident. Which collaborative intervention will be included in the
plan of care?...
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