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.