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.
B.
C.
D.

turn him frequently.

perform passive range-of-motion (ROM) exercises.
reduce the clients fluid intake.
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.
B.
C.
D.

Sit with the client for a few minutes.

Administer an analgesic.
Inform the nurse manager.
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.
B.
C.
D.

Perform passive range-of-motion (ROM) exercises.

Place the client on the affected side.
Use hand rolls or pillows for support.
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.
B.
C.
D.

prevent leaning
distribute weight away from the involved side
maintain stride length
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.
B.
C.
D.

Maintaining protein levels.

Maintaining vitamin levels.
Promoting weight-bearing exercises
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. Hes

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.
B.
C.
D.

checking stools for occult blood

performing range-of-motion exercises to the left side
keeping skin clean and dry
elevating the head of the bed to 30 degrees
7) Ms. Kelly. has had a CVA (cerebrovascular accident) and has severe rightsided 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 forward
8) 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.
B.
C.
D.

Weakened (L) side of the cient next to bed.

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

Receptive aphasia
Expressive aphasia
Global aphasia
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.
B.
C.
D.

Caucasian race
Female sex
Obesity
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.
B.
C.
D.

Turn him frequently.

Perform passive range-of-motion (ROM) exercises.
Reduce the clients fluid intake.
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.
B.
C.
D.

Polycythemia
Cardiomyopathy
Endocarditis
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.
B.
C.
D.

body temperature control.

balance and equilibrium.
visual acuity.
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.
B.
C.
D.

A cerebral vascular accident

Postoperative meningitis
Medication reaction
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.
C.

Most clients have residual effects after having a TIA.

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 Rationales

1.

2.

3.

4.

5.

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 isnt
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 doesnt 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.
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
clients condition. The physician will decide whether or not
administration of an analgesic is indicated. Informing the nurse
manager isnt necessary.
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.
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 wont maintain stride length or prevent
edema.
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 clients gag reflex is absent, elevating the head of the bed to 30
degrees helps minimize the clients 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 clients 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 Wernickes
aphasia, affects the ability to comprehend written or spoken words.
Expressive aphasia, also known as Brocas aphasia, affected the
patients 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 clients race, sex, and bronchial asthma arent
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 isnt
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 doesnt 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 bodys 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.