For a client with expressive aphasia, which of the following actions should RN implement to help the client communicate?

Ask simple simple “yes” or “no” questions

4 days after a CVA Pt becomes progressively lethargic and unable to articulate words when speaking. What is BEST action?

Notify the primary care provider immediately

RN is caring for a PT with a hemorrhagic stroke. Which of the following orders should the RN question?

Heparin 5000 units Subcut BID to prevent DVT

Pt w a history of TIA has takes aspirin 160 mg daily. Pt says, “I don’t have aches/ pains.” Which action should RN take?

Explain that the aspirin is ordered to decrease stroke risk.

Pt is experiencing R-sided arm and leg paralysis and facial drooping. Which of the following S&S should the RN expect?

Difficulty in understanding commands

RN is admitting a pt with L-sided homonymous hemianopsia from a stroke. Which intervention would be included?

Place objects needed for ADLs on the client’s right side.

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Strokes and TIA

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Answers

1
What is the most common type of stroke?
Thrombotic
Hemorrhagic
Subarachnoid
Embolic
2
For a client with expressive aphasia, which of the following actions should RN implement to help the client communicate?
Ask simple simple “yes” or “no” questions
Prevent embarrassing the client by changing the subject
Have the client practice facial and tongue exercises
Develop a list of words that the client can read and practice
3
4 days after a CVA Pt becomes progressively lethargic and unable to articulate words when speaking. What is BEST action?
Place the patient in the supine position
Assess the patient’s white blood cell count
Notify the primary care provider immediately
Document the findings as your only action
4
RN is caring for a PT with a hemorrhagic stroke. Which of the following orders should the RN question?
Insert foley catheter and measure urine output
Heparin 5000 units Subcut BID to prevent DVT
Oxygen at 3 L/min to keep O2 sat >92%
BP medication if diastolic BP is equal or over 110 mm Hg
5
Pt w a history of TIA has takes aspirin 160 mg daily. Pt says, “I don’t have aches/ pains.” Which action should RN take?
Explain that the aspirin is ordered to decrease stroke risk.
Tell the client that the aspirin is used to prevent aches.
Call the health care provider to clarify the medication order.
Document that the aspirin was refused by the client.
6
Pt with R-sided weakness that started 90 minutes earlier to the ED. Which of the following tests should be done first?
Chest radiograph (Chest x-ray)
Computed tomography (CT) scan
Complete blood count (CBC)
Electrocardiogram (ECG)
7
RN is admitting a client with L-sided hemiparesis in the ED. Which of the following actions should the nurse take first?
Obtain the Glasgow Coma Scale score
Monitor the blood pressure
Send the client for a CT scan
Check the airway
8
RN notes that the PT’s speech is slurred and the R hand grip is weak. It resolves after 30 minutes. What has occurred?
Hemorrhagic Stroke
TIA
Ischemic Stroke
CVA
9
Pt is experiencing R-sided arm and leg paralysis and facial drooping. Which of the following S&S should the RN expect?
Right-sided neglect
Hyperactive reflexes
Difficulty in understanding commands
Impulsive behaviour
10
RN is admitting a pt with L-sided homonymous hemianopsia from a stroke. Which intervention would be included?
Approach the client from the left side.
Reassure the client that the visual deficit will resolve
Place objects needed for ADLs on the client’s right side.
Apply an eye patch to the left eye.

Strokes and TIA Flashcards | StudBud