CVA ___1.

Which of the ff is the nurses first priority in caring for a pt with CVA whose BP is 160/100 and was observed to have left sided hemiplegia? A. help the family accept the condition B. promote a positive self image C. provide health teaching D. provide a safe environment ___2. Patients who are almost immobile often slide down in bed. Which of the ff device would be most useful in moving the pt up in bed? A. Pillows C. trapeze B. footboard D. draw sheet ___3. One of your nursing diagnosis for a pt with CVA is potential for impaired skin integrity related to immobility. Nursing intervention that would be most appropriate and practical for this pt is which of the ff? A. turn pt from side to side at least every 4 hrs B. request for waterbed or mattress under the pt C. facilitate daily hygienic practice every morning and as needed D. increase fluid intake ___4. Which of the ff are interdependent nursing interventions for a pt that is immobilized? 1. active or passive ROM exercise 2. deep breathing and coughing exercise 3. total parenteral nutrition and vitamin therapy 4. ADL as tolerated 5. change of position every 2 hrs and increased hydration A. 1,2,3 & 4 C. 1,3,4, & 5 B. 2,3,4 & 5 D. 1,2,4,& 5 ___5. The best position for a pt being moved up in bed is which of the ff? A. Sims position B. Prone with straight knees C. Supine with flexed knees D. Semi Fowlers position Mr. X44, 60 yrs old, has had cerebrovascular accident affecting the left cerebral hemisphere. (nos. 6- 10) ___6. The nurse would anticipate that Mr. X44 could have had motor weakness paralysis in which part of the body? A. bilateral in the lower extremity B. left side C. bilateral in the upper extremity D. right side ___7. Which of the ff conditions that may result from immobility is psychosocial in nature? A. physical restriction or limitation B. restriction in body position changes and posture C. physical inactivity D. sensory deprivation or alteration ___8. Which of the ff hazards of immobility common among patients with CVA affect the integumentary system? A. thrombus formation B. increased risk of pressure sores C. muscle atrophy D. contractures

___9. Decreased range of motion and muscle mass is beginning to be observed in which developmental stage? A. school age children C. adolescent B. pregnant women D. older adult ___10. The unprotected pressure points most associated in prolonged dorsal recumbent position which would most likely happen to Mr. X44 if left unchecked is which of the ff? A. sacrum C. lumbar B. knees D. toes ___11. The lobe of the cerebral cortex that registers general sensations such as heat, cold, pain and touch is: A. frontal lobe C. occipital B. parietal D. temporal ___12. One of the primary nursing objectives in a client with CVA is maintenance of airway. To achieve this objective, the nurse should initially place the client in the: A. prone position C. supine position B. lateral position D. trendelenburg position ___13. A client with dysphagia is experiencing: A. difficulty in writing C. difficulty in swallowing B. difficulty in focusing D.pain in urinating ___14. A client with CVA has dysarthria. Initial nursing care requires provision for: A. liquid formula diet B. routine hygienic needs C. prevention of aspiration D. effective communication ___15. Forty- eight hours following CVA, the nurse should institute which of the ff interventions? A. active exercise of all extremities B. passive range of motion exercises C. light weight lifting exercises of the right side D. exercises that would actively capitalize on returning muscle function ___16. A client with CVA has right hemiplegia. The blood pressure should not be obtained from the right arm because circulatory impairment may: A. produce inaccurate readings B. hinder restoration of function C. precipitate a formation of thrombus D. cause excessive pressure on the brachial artery ___17. The nurse would expect the client with CVA involving the right cerebral cortex and cranial nerves and resulting in a left hemiplegia to demonstrate paralysis of the left: A. lower extremity and lower haw B. arm , left leg and left side of the face C. arm , left leg and right side of the face D. upper extremity and left side of the face ___18. an immobilized patient with CVA should be turned to sides at least: A. 2 hrs C. 4 hrs B. 3 hrs D. 6 hrs

___19. A patient with CVA exhibits visual disturbances. The nurse knows that the patient has a possible lesion or tumor in the: A. Temporal lobe C. Left hemisphere B. Parietal lobe D. Occipital lobe ___20. Priority nursing diagnosis for patients with aphasia would be: A. Ineffective individual coping B. Impaired verbal communication C. Potential for injury D. Body image disturbance ___21. a patient was diagnosed with left cerebral thrombosis. This is disorder of the: A. Left body part, left face B. Right body part, right face C. Right body part left face D. Left body part right face ___22. The nurse recognizes that one major early problem in a patient with quadriplegia will be: A. Bladder control B. Nutritional intake C. Breathing D. Ambulation ___23 To prevent the development of contractures, careful consideration must be given to: A. Active exercise B. Deep massage C. Use of restraints D. Proper positioning ___24. Turning the patient every 1 to 2 hours done primarily to: A. Prevent pressure ulcers B. Promote comfort C. Prevent flexion contractures of the extremities D. Improve circulation in the different body parts