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The nurse is assessing a client experiencing motor loss as a result of a left-sided cerebral vascular 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 hte body and ataxia
3. Homonymous heminopsia and diplopia
4. impulsive behavior and hostility toward family.
2. The most common motor dysfunction of the 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 coordinate movement
A 78 year old client is admitted to the emergency department with numbness and weakness 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.
3. A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological
- disorder. If CVA is diagnosed, the CT scan can determine if it is a hemorrhagic or ischemic accident
- and guide treatment.
Which client would the nurse identify as being most at risk for experiencing a CVA?
1. A 55 year old African American male.
2. A 84 year old Japanese female.
3. A 67 year old Cacasian male.
4. A 39 year old pregnant female
1. African-Americans have twice the rate of CVAs as Causasians and men have a
- higher incidence than women; African Americans suffer more extensive damage from a CVA than do
- people of other cultural groups
The client diagnosed with a right sided cerebrovascular accident is admitted to the rehabilitation unit.
Which intervention 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.
- 1. Placing a small pillow under the shoulder will prevent the shoulder from adducting toward the chest
- and developing a contracture.
- 3. The client should not ignore the paralyzed side, and the nurse must encourage the client to move it as
- much as possible; a written schedule may assist the client in exercising.
The Nurse is planning care for a client experiencing agnosia(failure to recognize familar swallowing) secondary to a cerebrovascular accident. Which collaborative intervention will be included in the plan
1. Observing the client swallowing for possible aspirations
2. Positioning the client in a semi-fowler's position when sleeping
3. Placing a suction set-up at the clients bedside during meals
4. Referring the client to an occupational therapist for evaluation
4. A collaborative intervention is an intervention in which another health-care discipline-in this case,
occupational therapy- is used in the care of the client