1) A male client who has suffered a cerebrovascular accident (CVA) is too weak to move on his own. To help the client avoid pressure ulcers, the nurse should:

A. turn him frequently.B. perform passive range-of-motion (ROM) exercises.C. reduce the client’s fluid intake.D. encourage the client to use a footboard.

2) The nurse is caring for a male client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform?

A. Sit with the client for a few minutes.B. Administer an analgesic.C. Inform the nurse manager.D. Call the physician immediately.

3) Which action should take the highest priority when caring for a client with hemiparesis caused by a cerebrovascular accident (CVA)?

A. Perform passive range-of-motion (ROM) exercises.B. Place the client on the affected side.C. Use hand rolls or pillows for support.D. Apply antiembolism stockings

4) A client who recently had a cerebrovascular accident requires a cane to ambulate. When teaching about cane use, the rationale for holding a cane on the uninvolved side is to:

A. prevent leaningB. distribute weight away from the involved sideC. maintain stride lengthD. prevent edema

5) A 70 yr-old client with a diagnosis of leftsided cerebrovascular accident is admitted to the facility. To prevent the development of diffuse osteoporosis, which of the following objectives is most appropriate?

A. Maintaining protein levels.B. Maintaining vitamin levels.C. Promoting weight-bearing exercisesD. Promoting range-of-motion (ROM) exercises

6) After a cerebrovascular accident, a 75 yr old client is admitted to the health care facility. The client has left-sided weakness and an absent gag reflex.

He’s incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g/dl. Which of the following is a priority for this client?

A. checking stools for occult bloodB. performing range-of-motion exercises to the left sideC. keeping skin clean and dryD. elevating the head of the bed to 30 degrees

7) Ms. Kelly. has had a CVA (cerebrovascular accident) and has severe right-sided weakness. She has been taught to walk with a cane. The nurse is evaluating her use of the cane prior to discharge. Which of the following reflects correct use of the cane?

A. Holding the cane in her left hand, Ms. Kelly. moves the cane forward first, then her right leg, and finally her left leg

B. Holding the cane in her right hand, Ms. Kelly. moves the cane forward first, then her left leg, and finally her right leg

C. Holding the cane in her right hand, Ms. Kelly. moves the cane and her right leg forward, then moves her left leg forward.

D. Holding the cane in her left hand, Ms. Kelly. moves the cane and her left leg forward, then moves her right leg forward8) The client has had a right-sided cerebrovascular accident. In transferring the client from the wheelchair to bed, in what position should a client be placed to facilitate safe transfer?

A. Weakened (L) side of the cient next to bed.B. Weakened (R) side of the client next to bed.C. Weakened (L) side of the client away from bed.D. Weakened (R) side of the cient away from bed.

9) Gary Jordan suffered a cerebrovascular accident that left her unable to comprehend speech and unable to speak. This type of aphasia is known as:

A. Receptive aphasiaB. Expressive aphasiaC. Global aphasiaD. Conduction aphasia

10) A white female client is admitted to an acute care facility with a diagnosis of cerebrovascular accident (CVA). Her history reveals bronchial asthma, exogenous obesity, and iron deficiency anemia. Which history finding is a risk factor for CVA?

A. Caucasian raceB. Female sexC. ObesityD. Bronchial asthma

11) Mr. Mendoza who has suffered a cerebrovascular accident (CVA) is too weak to move on his own. To help the client avoid pressure ulcers, Nurse Celia should:

A. Turn him frequently.B. Perform passive range-of-motion (ROM) exercises.C. Reduce the client’s fluid intake.D. Encourage the client to use a footboard.

12) Which of the following is most likely associated with a cerebrovascular accident (CVA) resulting from congenital heart disease?

A. PolycythemiaB. CardiomyopathyC. EndocarditisD. Low blood pressure

13) If a male client experienced a cerebrovascular accident (CVA) that damaged the hypothalamus, the nurse would anticipate that the client has problems with:

A. body temperature control.B. balance and equilibrium.C. visual acuity.D. thinking and reasoning.

14) A nurse is caring for a 2 year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the child has suddenly begun seizing. The nurse recognizes this problem is probably due to

A. A cerebral vascular accidentB. Postoperative meningitisC. Medication reactionD. Metabolic alkalosis

15) The nurse is formulating a teaching plan for a client who has just experienced a transient ischemic attack (TIA). Which fact should the nurse include in the teaching plan?

A. TIA symptoms may last 24 to 48 hours.

B. Most clients have residual effects after having a TIA.C. TIA may be a warning that the client may have cerebrovascular

accident (CVA)D. The most common symptom of TIA is the inability to speak.

Answers and Rationales1. A. turn him frequently. The most important intervention to

prevent pressure ulcers is frequent position changes, which relieve pressure on the skin and underlying tissues. If pressure isn’t relieved, capillaries become occluded, reducing circulation and oxygenation of the tissues and resulting in cell death and ulcer formation. During passive ROM exercises, the nurse moves each joint through its range of movement, which improves joint mobility and circulation to the affected area but doesn’t prevent pressure ulcers. Adequate hydration is necessary to maintain healthy skin and ensure tissue repair. A footboard prevents plantar flexion and footdrop by maintaining the foot in a dorsiflexed position.

2. D. Call the physician immediately. The headache may be an indication that the aneurysm is leaking. The nurse should notify the physician immediately. Sitting with the client is appropriate but only after the physician has been notified of the change in the client’s condition. The physician will decide whether or not administration of an analgesic is indicated. Informing the nurse manager isn’t necessary.

3. B. Place the client on the affected side. To help prevent airway obstruction and reduce the risk of aspiration, the nurse should position a client with hemiparesis on the affected side. Although performing ROM exercises, providing pillows for support, and applying antiembolism stockings can be appropriate for a client with CVA, the first concern is to maintain a patent airway.

4. B. distribute weight away from the involved side. Holding a cane on the uninvolved side distributes weight away from the involved side. Holding the cane close to the body prevents leaning. Use of a cane won’t maintain stride length or prevent edema.

5. C. Promoting weight-bearing exercises . When the mechanical stressors of weight bearing are absent, diffuse osteoporosis can occur. Therefore, if the client does weight-bearing exercises, disuse complications can be prevented. Maintaining protein and vitamins levels is important, but neither will prevent osteoporosis. ROM exercises will help prevent muscle atrophy and contractures.

6. D. elevating the head of the bed to 30 degrees . Because the client’s gag reflex is absent, elevating the head of the bed to 30 degrees helps minimize the client’s risk of aspiration. Checking the stools, performing ROM exercises, and keeping the skin clean and dry are important, but preventing aspiration through positioning is the priority.

7. A. Holding the cane in her left hand, Ms. Kelly. moves the cane forward first, then her right leg, and finally her left leg . When a person with weakness on one side uses a cane, there should always be two points of contact with the floor. When Ms. Kelly. moves the cane forward, she has both feet on the floor, providing stability. As she moves the weak leg, the cane and the strong leg provide support. Finally, the cane, which is even with the weak leg, provides stability while she moves the strong leg. She should not hold the cane with her weak arm. The use of the cane requires arm strength to ensure that the cane provides adequate stability when standing on the weak leg. The cane should be held in the left hand, the hand opposite the affected leg. If Ms. Kelly. moved the cane and her strong foot at the same time, she would be left standing on her weak leg at one point. This would be unstable at best; at worse, impossible

8. C. Weakened (L) side of the client away from bed. With a right-sided cerebrovascular accident the client would have left-sided hemiplegia or weakness. The client’s good side should be closest to the bed to facilitate the transfer.

9. C. Global aphasia . Global aphasia occurs when all language functions are affected. Receptive aphasia, also known as Wernicke’s aphasia, affects the ability to comprehend written or spoken words. Expressive aphasia, also known as Broca’s aphasia, affected the patient’s ability to form language and express thoughts. Conduction aphasia refers to abnormalities in speech repetition.

10. C. Obesity . Obesity is a risk factor for CVA. Other risk factors include a history of ischemic episodes, cardiovascular disease, diabetes mellitus, atherosclerosis of the cranial vessels, hypertension, polycythemia, smoking, hypercholesterolemia, oral contraceptive use, emotional stress, family history of CVA, and advancing age. The client’s race, sex, and bronchial asthma aren’t risk factors for CVA.

11. A. Turn him frequently. The most important intervention to prevent pressure ulcers is frequent position changes, which relieve pressure on the skin and underlying tissues. If pressure isn’t

relieved, capillaries become occluded, reducing circulation and oxygenation of the tissues and resulting in cell death and ulcer formation. During passive ROM exercises, the nurse moves each joint through its range of movement, which improves joint mobility and circulation to the affected area but doesn’t prevent pressure ulcers. Adequate hydration is necessary to maintain healthy skin and ensure tissue repair. A footboard prevents plantar flexion and footdrop by maintaining the foot in a dorsiflexed position.

12. A. Polycythemia. The child with congenital heart disease develops polycythemia resulting from an inadequate mechanism to compensate for decreased oxygen saturation

13. A. body temperature control. The body’s thermostat is located in the hypothalamus; therefore, injury to that area can cause problems of body temperature control. Balance and equilibrium problems are related to cerebellar damage. Visual acuity problems would occur following occipital or optic nerve injury. Thinking and reasoning problems are the result of injury to the cerebrum.

14. A. A cerebral vascular accident . Polycythemia occurs as a physiological reaction to chronic hypoxemia which commonly occurs in clients with Tetralogy of Fallot. Polycythemia and the resultant increased viscosity of the blood increase the risk of thromboembolic events. Cerebrovascular accidents may occur. Signs and symptoms include sudden paralysis, altered speech, extreme irritability or fatigue, and seizures.

15. C. TIA may be a warning that the client may have cerebrovascular accident (CVA). TIA may be a warning that the client will experience a CVA, or stroke, in the near future. TIA aymptoms last no longer than 24 hours and clients usually have complete recovery after TIA. The most common symptom of TIA is sudden, painless loss of vision lasting up to 24 hours.