Cerebrovascular Disorders (chpt 47)
A nurse is instructing the spouse of a client who suffered a stroke about the use of eating devices the client will be using. During the teaching, the spouse starts to cry and states, "One minute he is laughing, and the next he's crying; I just don't understand what's wrong with him." Which statement is the best response by the nurse? "This behavior is common in clients with stroke. Which does your spouse do more often? Laugh or cry?" "You seem upset, and it may be hard for you to focus on the teaching, I'll come back later." "Emotional lability is common after a stroke, and it usually improves with time." "You sound stressed; maybe using some stress management techniques will help."
"Emotional lability is common after a stroke, and it usually improves with time." Explanation: This is the most therapeutic and informative response. Often, most relatives of clients with stroke handle the physical changes better than the emotional aspects of care. The family should be prepared to expect occasional episodes of emotional lability. The client may laugh or cry easily and may be irritable and demanding or depressed and confused. The nurse can explain to the family that the client's laughter does not necessarily connote happiness, nor does crying reflect sadness, and that emotional lability usually improves with time. The remaining responses are nontherapeutic and do not address the spouse's concerns
The nurse knows that symptoms associated with a TIA, usually a precursor of a future stroke, usually subside in what period of time? 3 to 6 hours 24 to 36 hours 1 hour 12 hours
1 hour Explanation: A transient ischemic attack (TIA) is a neurologic deficit typically lasting less than 1 hour. A TIA is manifested by a sudden loss of motor, sensory, or visual function. The symptoms result from temporary ischemia (impairment of blood flow) to a specific region of the brain; however, when brain imaging is performed, there is no evidence of ischemia.
The nurse understands the urgency of timely intervention for an ischemic stroke. Based on her knowledge of cerebral blood flow (normal CBF = 50 to 55 mL/100 g/min) and obstruction, she is aware that neurons will no longer maintain aerobic respiration at which level of CBF? 45 to 50 mL/100 g/min 15 to 20 mL/100 g/min 35 to 45 mL/100 g/min 35 to 45 mL/100 g/min
15 to 20 mL/100 g/min Explanation: Cerebral blood flow of less than 25 mL/100g/min is the threshold for electrical failure. Refer to Figure 47-4 in the text.
A patient is admitted via ambulance to the emergency room of a stroke center at 1:30 p.m. with symptoms that the patient said began at 1:00 p.m. Within 1 hour, an ischemic stroke had been confirmed and the doctor ordered tPA. The nurse knows to give this drug no later than what time? 2:00 p.m. 3:00 p.m. 4:00 p.m. 7:00 p.m.
4:00 p.m. Explanation: Tissue plasminogen activator (tPA) must be given within 3 hours after symptom onset. Therefore, since symptom onset was 1:00 pm, the window of opportunity ends at 4:00 pm.
The nurse is aware that in an ischemic stroke there is an area of low CBF around the infracted area (penumbra region). This area cannot be saved if tissue plasminogen activator (tPA) is administered at a CBF level of: 28 mL/100 g/min. 48 mL/100 g/min. 38 mL/100 g/min. 8 mL/100 g/min.
8 mL/100 g/min. Explanation: There is tissue viability up to 10 mL/100 g/min. When CBF is less than 10 mL/100 g/min, cellular death occurs. Refer to Figure 47-4 in the text.
A nurse is teaching a community group about modifiable and nonmodifiable risk factors for ischemic strokes. Which of the following is a risk factor that cannot be modified? Obesity Hypertension Advanced age Atrial fibrillation
Advanced age Explanation: Modifiable risk factors for ischemic stroke include hypertension, atrial fibrillation, hyperlipidemia, diabetes mellitus, smoking, asymptomatic carotid stenosis, obesity, and excessive alcohol consumption. Advanced age is a nonmodifiable risk factor.
Which term refers to the failure to recognize familiar objects perceived by the senses? Apraxia Agraphia Agnosia Perseveration
Agnosia Explanation: Auditory agnosia is failure to recognize significance of sounds. Agraphia refers to disturbances in writing intelligible words. Apraxia refers to an inability to perform previously learned purposeful motor acts on a voluntary basis. Perseveration is the continued and automatic repetition of an activity, word, or phrase that is no longer appropriate.
When caring for a patient who has had a hemorrhagic stroke, close monitoring of vital signs and neurological status is imperative. What is the earliest sign of deterioration in a patient with a hemorrhagic stroke? Tonic-clonic seizures Headache Alteration in level of consciousness (LOC) Shortness of breath
Alteration in level of consciousness (LOC) Explanation: Alteration in LOC is the earliest sign of deterioration in a patient with a hemorrhagic stroke; these include mild drowsiness, slight slurring of speech, and sluggish papillary reaction.
Which term refers to the inability to perform previously learned purposeful motor acts on a voluntary basis? Agnosia Perseveration Agraphia Apraxia
Apraxia Explanation: Verbal apraxia refers to difficulty forming and organizing intelligible words although the musculature is intact. Agnosia is a failure to recognize familiar objects perceived by the senses. Agraphia refers to disturbances in writing intelligible words. Perseveration is the continued and automatic repetition of an activity or word or phrase that is no longer appropriate.
A patient has been admitted to a unit at a primary stroke center after experiencing an ischemic stroke. The nurse on the unit is aware of the vital importance of rehabilitative efforts and knows that an active rehabilitation program should begin at what point? As soon as moderate motor activity is regained on the affected side As soon as sensory ability is regained on the affected side As soon as the patient regains consciousness As soon as the patient is able to independently identify goals for rehabilitation
As soon as the patient regains consciousness Explanation: Usually an active rehabilitation program is started as soon as the patient regains consciousness. It would be erroneous to wait until the affected side recovers. Patients may benefit from rehabilitation before they are able to independently set goals.
Which of the following, if left untreated, can lead to an ischemic stroke? Ruptured cerebral arteries Cerebral aneurysm Atrial fibrillation Arteriovenous malformation (AVM)
Atrial fibrillation Explanation: Atrial fibrillation is the most frequently diagnosed arrhythmia in the United States. If left untreated, it can lead to an ischemic stroke. Cerebral hemorrhage, arteriovenous malformation, and cerebral hemorrhage can lead to a hemorrhagic stroke. Cerebral aneurysm, arteriovenous malformations, and ruptured cerebral arteries can lead to hemorrhagic stroke.
A client has experienced an ischemic stroke that has damaged the temporal (lateral and superior portions) lobe. Which of the following deficits would the nurse expect during assessment of this client? Hemiplegia or hemiparesis Auditory agnosia Limited attention span and forgetfulness Lack of deep tendon reflexes
Auditory agnosia Explanation: Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia. If damage has occurred to the frontal lobe, learning capacity, memory, or other higher cortical intellectual functions may be impaired. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and lack of motivation. Damage to motor neurons may cause hemiparesis, hemiplegia, and a change in reflexes.
A patient who just suffered a hemorrhagic stroke is brought to the emergency department by ambulance. What should be the nurse's primary assessment focus? Urinary output Fluid and electrolyte balance Seizure activity Cardiac and respiratory status
Cardiac and respiratory status Explanation: Acute care begins with managing the ABC's. Patients may have difficulty keeping an open and clear airway secondary to decreased level of consciousness. Neurological assessment with close monitoring for signs of increased neurological deficit and seizure activity occurs next. Fluid and electrolyte balance must be controlled carefully, with the goal of adequate hydration to promote perfusion and decrease further brain damage.
The provider diagnoses the patient as having had an ischemic stroke. The etiology of an ischemic stroke would include which of the following? Arteriovenous malformation Cardiogenic emboli Cerebral aneurysm Intracerebral hemorrhage
Cardiogenic emboli Explanation: Aneurysms, hemorrhages, and malformations are all examples of a hemorrhagic stroke. An embolism can block blood flow, leading to ischemia.
A 76-year-old client is brought to the clinic by his daughter. The daughter states that her father has had two transient ischemic attacks (TIAs) in the past week. The physician orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option does the nurse expect the physician to offer this client to increase blood flow to the brain? Stent placement Removal of the carotid artery Percutaneous transluminal coronary artery angioplasty Carotid endarterectomy
Carotid endarterectomy Explanation: If narrowing of the carotid artery by atherosclerotic plaques is the cause of the TIAs, a carotid endarterectomy (surgical removal of atherosclerotic plaque) is a treatment option. A balloon angioplasty, a procedure similar to a percutaneous transluminal coronary artery angioplasty, is performed to dilate the carotid artery and increase blood flow to the brain. Options A, B, and C are not surgical options to increase blood flow through the carotid artery to the brain.
A patient presents to the emergency room with complaints of having an "exploding headache" for the last 2 hours. The patient is immediately seen by a triage nurse who suspects the patient is experiencing a stroke. Which of the following is a possible cause based on the characteristic symptom? Cerebral aneurysm Cardiogenic emboli Large artery thrombosis Small artery thrombosis
Cerebral aneurysm Explanation: A cerebral aneurysm is a type of hemorrhagic stroke that is characterized by an exploding headache.
A female patient who is recovering from a stroke has begun eating a minced and pureed diet after passing the speech pathologist's swallowing assessment. This morning, the nurse set up the patient with her breakfast tray and later noticed that the woman was swallowing her food well but dribbling small amounts of food out of affected side of her mouth. How should the nurse follow up this observation? Provide oral suctioning after each bite that the patient swallows. Cue the patient to the fact that she is dribbling food while commending her for eating. Remove the patient's tray because of the risk of aspiration. Make the patient NPO and encourage the care provider to consider enteral nutrition.
Cue the patient to the fact that she is dribbling food while commending her for eating. Explanation: Dribbling of food should be noted and addressed but does not necessarily constitute an acute risk of aspiration. Close observation is warranted but enteral feeding and NPO status are not likely necessary. Suctioning after each bite of food is not necessary.
The nurse is caring for a client with a history of transient ischemic attacks (TIAs) and moderate carotid stenosis who has undergone a carotid endarterectomy. Which postoperative finding would cause the nurse the most concern? Neck pain rated 3 of 10 (on a 0 to 10 pain scale) Blood pressure 128/86 mm Hg Difficulty swallowing Mild neck edema
Difficulty swallowing Explanation: The client's inability to swallow without difficulty would cause the nurse the most concern. Difficulty swallowing, hoarseness, or other signs of cranial nerve dysfunction must be assessed. The nurse focuses on assessment of the following cranial nerves: facial (VII), vagus (X), spinal accessory (XI), and hypoglossal (XII). Some edema in the neck after surgery is expected; however, extensive edema and hematoma formation can obstruct the airway. Emergency airway supplies, including those needed for a tracheostomy, must be available. The client's neck pain and mildly elevated blood pressure need to be addressed but would not cause the nurse the most concern. Hypotension is avoided to prevent cerebral ischemia and thrombosis. Uncontrolled hypertension may precipitate cerebral hemorrhage, edema, hemorrhage at the surgical incision, or disruption of the arterial reconstruction.
After a stroke, a client is admitted to the 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. Which nursing intervention is a priority for this client? Elevating the head of the bed to 30 degrees Keeping skin clean and dry Performing range-of-motion (ROM) exercises on the left side Checking stools for occult blood
Elevating the head of the bed to 30 degrees Explanation: 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.
A nurse has developed a strong therapeutic rapport with a male patient during the patient's recovery in hospital from a stroke. The patient has had a largely successful recovery but has admitted to the nurse that he has concerns about how his sexual relationship will be affected upon discharge. The nurse should respond to the patient's statement by: Encouraging him with the fact that this aspect of his life is not likely to have been affected by his stroke Encouraging him to consider alternative forms of sexual expression with his partner Encouraging him to focus on his achievements rather than his perceived deficits Encouraging him to prioritize the emotional aspects of his relationship rather than the physical aspects
Encouraging him to consider alternative forms of sexual expression with his partner Explanation: Encouraging the patient to explore alternative methods of sexual expression acknowledges the patient's concerns and provides a realistic and empathic response. It is inappropriate to divert the patient's concerns or to provide unrealistic expectations.
How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tPA)? Every 30 minutes Every hour Every 45 minutes Every 15 minutes
Every 15 minutes Explanation: Neurological assessment and vital signs (except temperature) should be taken every 15 minutes initially while the patient is receiving tPA infusion.
A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to perform which action? Form words that are understandable or comprehend spoken words Comprehend spoken words Form words that are understandable Speak at all
Form words that are understandable or comprehend spoken words Explanation: Global aphasia is a combination of expressive and receptive aphasia and presents a tremendous challenge to the nurse to effectively communicate with the client. In receptive and expressive aphasia, the client is unable to form words that are understandable. The client who is unable to speak at all is referred to as mute.
From which direction should a nurse approach a client who is blind in the right eye? From directly in front of the client From the right side of the client From the left side of the client From directly behind the client
From the left side of the client Explanation: The nurse should approach the client from the left side so that the client can be aware of the nurse's approach. Likewise, personal items should be placed on the client's left side so that he can see them easily.
A stroke victim is experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe? Parietal Occipital Temporal Frontal
Frontal Explanation: If damage has occurred to the frontal lobe, learning capacity, memory, or other higher cortical intellectual functions may be impaired. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and a lack of motivation.
A client undergoes cerebral angiography for evaluation of a subarachnoid hemorrhage. Which findings indicate spasm or occlusion of a cerebral vessel by a clot? Hemiplegia, seizures, and decreased level of consciousness Difficulty breathing or swallowing Tachycardia, tachypnea, and hypotension Nausea, vomiting, and profuse sweating
Hemiplegia, seizures, and decreased level of consciousness Explanation: Spasm or occlusion of a cerebral vessel by a clot causes signs and symptoms similar to those of a stroke: hemiplegia, seizures, decreased level of consciousness, aphasia, hemiparesis, and increased focal symptoms. Nausea, vomiting, and profuse sweating suggest a delayed reaction to the contrast medium used in cerebral angiography. Difficulty breathing or swallowing may signal a hematoma in the neck. Tachycardia, tachypnea, and hypotension suggest internal hemorrhage.
An emergency department (ED) nurse has administered an ordered bolus of tissue plasminogen activator (tPA) to a male patient who was diagnosed with stroke. During the administration of tPA, the nurse should prioritize assessments related to what problem? Peripheral edema Fluid overload Hemorrhage Acute pain
Hemorrhage Explanation: Bleeding is the most common side effect of tPA. The patient is closely monitored for bleeding (at IV insertion sites, gums, urine/stools, and intracranially by assessing changes in level of consciousness). Edema, fluid overload, and pain are not likely to result from tPA.
A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? Heparin sodium Phenytoin Methyldopa Dexamethasone
Heparin sodium Explanation: Administering heparin, an anticoagulant, could increase the bleeding associated with hemorrhagic stroke. Therefore, the nurse should question this order to prevent additional hemorrhage in the brain. In a client with hemorrhagic stroke, the healthcare provider may use dexamethasone (Decadron) to decrease cerebral edema and pressure, methyldopa (Aldomet) to reduce blood pressure, and phenytoin (Dilantin) to prevent seizures.
The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regimen, to maintain a healthy weight, and to adopt a reasonable exercise program. This advice is based on research data that shows the most important risk factor for stroke is: Obesity Dyslipidemia Hypertension Smoking
Hypertension Explanation: Hypertension is the most modifiable risk factor for either ischemic or hemorrhagic stroke. Unfortunately, it remains under-recognized and undertreated in most communities.
A client diagnosed with migraine headaches asks the nurse what to do to help control the headaches and minimize the number of attacks the client is having. What instructions should the nurse give this client? Write down any adverse drug effects. When an attack occurs, stay in a brightly lit area. Keep a record of activities following an attack. Identify and avoid factors that precipitate or intensify an attack.
Identify and avoid factors that precipitate or intensify an attack. Explanation: The nurse includes the following instructions: Follow the indications and dosage regimen for medication and notify the physician of any adverse drug effects. Identify and avoid factors that precipitate or intensify an attack. Keep a food diary, which may help identify foods that trigger attacks. Keep a record of the attacks, including activities before the attack and environmental or emotional circumstances that appear to bring on the attack. Lie down in a darkened room and avoid noise and movement when an attack occurs, if that is possible.
A client is receiving an IV infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To confirm that this drug is producing its therapeutic effect, the nurse should consider which finding most significant? Decreased level of consciousness (LOC) Increased urine output Elevated blood pressure Decreased heart rate
Increased urine output Explanation: The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output. A decreased LOC and elevated blood pressure may indicate lack of therapeutic effectiveness. A decreased heart rate doesn't indicate that mannitol is effective.
An emergency department nurse is interviewing a client who is presenting with signs of an ischemic stroke that began 2 hours ago. The client reports a history of a cholecystectomy 6 weeks ago and is taking digoxin, warfarin, and labetalol. What factor poses a threat to the client for thrombolytic therapy? Taking digoxin Two hour time period of the stroke International normalized ratio greater than 2 Surgery 6 weeks ago
International normalized ratio greater than 2 Explanation: The client is at risk for further bleeding if the international normalized ratio is greater than 2. Thrombolytic therapy must be initiated within 3 hours in clients with ischemic stroke. The client is not eligible for thrombolytic therapy if she has had surgery within 14 days. Digoxin and labetalol do not prohibit thrombolytic therapy.
Which interventions would be recommended for a client with dysphagia? Select all that apply. Assist the client with meals. Test the gag reflex before offering food or fluids. Place food on the affected side of the mouth. Allow ample time to eat.
Interventions for dysphagia include placing food on the unaffected side of the mouth, allowing ample time to eat, assisting the client with meals, and testing the client's gag reflex before offering food or fluids.
Which is a contraindication for the administration of tissue plasminogen activator (t-PA)? Systolic blood pressure less than or equal to 185 mm Hg Age 18 years or older Ischemic stroke Intracranial hemorrhage
Intracranial hemorrhage Explanation: Intracranial hemorrhage, neoplasm, and aneurysm are contraindications for t-PA. Clinical diagnosis of ischemic stroke, age 18 years or older, and a systolic blood pressure less than or equal to 185 mm Hg are eligibility criteria.
The nurse is caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke does the nurse know this client has? Ischemic Hemorrhagic Right-sided Left-sided
Ischemic Explanation: Ischemic strokes occur when a thrombus or embolus obstructs an artery carrying blood to the brain; about 80% of strokes are the ischemic variety. The other options are incorrect.
A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention? Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess Maintaining the client in a quiet environment Keeping the client in one position to decrease bleeding Positioning the client to prevent airway obstruction
Keeping the client in one position to decrease bleeding Explanation: The student nurse shouldn't keep the client in one position. She should carefully reposition the client often (at least every hour). The client needs to be positioned so that a patent airway can be maintained. Fluid administration must be closely monitored to prevent complications such as increased intracranial pressure. The client must be maintained in a quiet environment to decrease the risk of rebleeding.
A client has experienced an ischemic stroke that has damaged the lower motor neurons of the brain. Which of the following deficits would the nurse expect during assessment? Visual agnosia Auditory agnosia Lack of deep tendon reflexes Limited attention span and forgetfulness
Lack of deep tendon reflexes Explanation: Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia. If damage has occurred to the frontal lobe, learning capacity, memory, or other higher cortical intellectual functions may be impaired. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and lack of motivation. Damage to the lower motor neurons may cause decreased muscle tone, flaccid muscle paralysis, and a decrease in or loss of reflexes.
Which of the following is accurate regarding a hemorrhagic stroke? One of the main presenting symptoms is numbness or weakness of the face. Main presenting symptom is an "exploding headache." Functional recovery usually plateaus at 6 months. It is caused by a large-artery thrombosis.
Main presenting symptom is an "exploding headache." Explanation: One of hemorrhagic stroke's main presenting symptom is an "exploding headache." In ischemic stroke, functional recovery usually plateaus at 6 months; it may be caused by a large artery thrombosis and may have a presenting symptoms of numbness or weakness of the face.
A nurse is caring for a client with a cerebral aneurysm. Which nursing interventions would be most useful to the nurse to avoid bleeding in the brain? Select all that apply. Follow the healthcare provider's orders to increase fluid volume. Use a well-lighted room for assessments every 2 hours. Report changes in neurologic status as soon as a worsening trend is identified. Avoid any activities that cause a Valsalva maneuver. Maintain the head of the bed at 30 degrees.
Maintain the head of the bed at 30 degrees. Avoid any activities that cause a Valsalva maneuver. Report changes in neurologic status as soon as a worsening trend is identified. Cerebral aneurysm precautions are implemented for the patient with a diagnosis of aneurysm to provide a nonstimulating environment, prevent increases in intracranial pressure, and prevent further bleeding. The patient is placed on bed rest in a quiet, nonstressful environment, because activity, pain, and anxiety are thought to elevate the blood pressure, which may increase the risk for bleeding. The head of the bed is elevated 30 degrees to promote venous drainage and decrease intracranial pressure. Any activity that suddenly increases the blood pressure or obstructs venous return is avoided. This includes the Valsalva maneuver, straining, forceful sneezing, pushing oneself up in bed and acute flexion or rotation of the head and neck (which compromises the jugular veins). Stool softeners and mild laxatives are prescribed to prevent constipation, which can cause an increase in intracranial pressure. Dim lighting is helpful for photophobia. Increasing fluid volume does not affect brain bleeding
The nurse is caring for a client diagnosed with a hemorrhagic stroke. The nurse recognizes that which intervention is most important? Administering a stool softener Maintaining a patent airway Monitoring for seizure activity Elevating the head of the bed to 30 degrees
Maintaining a patent airway Explanation: Maintaining the airway is the most important nursing intervention. Immediate complications of a hemorrhagic stroke include cerebral hypoxia, decreased cerebral blood flow, and extension of the area of injury. Providing adequate oxygenation of blood to the brain minimizes cerebral hypoxia. Brain function depends on delivery of oxygen to the tissues. Administering supplemental oxygen and maintaining hemoglobin and hematocrit at acceptable levels will assist in maintaining tissue oxygenation. All other interventions are appropriate, but the airway takes priority. The head of the bed should be elevated to 30 degrees, monitoring the client because of the risk for seizures, and stool softeners are recommended to prevent constipation and straining, but these are not the most important interventions.
Which clinical manifestation would be exhibited by a client following a hemorrhagic stroke of the right hemisphere? Expressive aphasia Neglect of the left side Inability to move the right arm Neglect of the right side
Neglect of the left side Explanation: This client would have deficits on the left side. Expressive aphasia typically occurs with left-hemisphere stroke.
A patient is brought to the emergency department with a possible stroke. What initial diagnostic test for a stroke, usually performed in the emergency department, would the nurse prepare the patient for? 12-lead electrocardiogram Carotid ultrasound study Transcranial Doppler flow study Noncontrast computed tomogram
Noncontrast computed tomogram Explanation: The initial diagnostic test for a stroke is usually a noncontrast computed tomography (CT) scan. This should be performed within 25 minutes or less from the time the patient presents to the emergency department (ED) to determine if the event is ischemic or hemorrhagic (the category of stroke determines treatment).
Which set of symptoms characterize Korsakoff syndrome? Choreiform movement and dementia Psychosis, disorientation, delirium, insomnia, and hallucinations Severe dementia and myoclonus Tremor, rigidity, and bradykinesia
Psychosis, disorientation, delirium, insomnia, and hallucinations Explanation: Korsakoff syndrome is a personality disorder characterized by psychosis, disorientation, delirium, insomnia, and hallucinations. Creutzfeldt-Jacob disease results in severe dementia and myoclonus. The three cardinal signs of Parkinson disease are tremor, rigidity, and bradykinesia. Huntington disease results in progressive involuntary choreiform (dancelike) movements and dementia.
A client on your unit is scheduled to have intracranial surgery in the morning. Which nursing intervention helps to avoid intraoperative complications, reduce cerebral edema, and prevent postoperative vomiting? Administer preoperative sedation. Restrict fluids before surgery. Administer prescribed medications. Administer an osmotic diuretic.
Restrict fluids before surgery. Explanation: Before surgery, the nurse should restrict fluids to avoid intraoperative complications, reduce cerebral edema, and prevent postoperative vomiting. The nurse administers prescribed medications such as an anticonvulsant phenytoin, like Dilantin, to reduce the risk of seizures before and after surgery, an osmotic diuretic, and corticosteroids. Preoperative sedation is omitted.
The nurse practitioner is able to correlate a patient's neurologic deficits with the location in the brain affected by ischemia or hemorrhage. For a patient with a left hemispheric stroke, the nurse would expect to see: Right-sided paralysis. Spatial-perceptual deficits. Impulsive behavior. Left visual field deficit.
Right-sided paralysis. Explanation: A left hemispheric stroke will cause right-sided weakness or paralysis. Because upper motor neurons decussate, a disturbance on one side of the body can cause damage on the opposite side of the brain. Refer to Box 47-2 in the text.
The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient? High-Fowler's Supine Semi-Fowler's Prone
Semi-Fowler's Explanation: The head of the bed is elevated 15 to 30 degrees (semi-Fowler's position) to promote venous drainage and decrease intracranial pressure.
While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are: Foot drop and external hip rotation Weakness on one side of the body and difficulty with speech Confusion or change in mental status Severe headache and early change in level of consciousness
Severe headache and early change in level of consciousness Explanation: The main presenting symptoms for ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body, confusion or change in mental status, and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Foot drop and external hip rotation can occur if a stroke victim is not turned or positioned correctly.
The nurse is caring for a client recovering from a carotid endarterectomy. Which finding indicates to the nurse that the client is experiencing hyperperfusion syndrome? Change in vision in one eye Decreased blood pressure Difficulty breathing Severe unilateral headache
Severe unilateral headache Explanation: Hyperperfusion syndrome occurs when cerebral vessel autoregulation fails. Arteries accustomed to diminished blood flow may be permanently dilated. Increased blood flow after endarterectomy coupled with insufficient vasoconstriction leads to capillary bed damage, edema, and hemorrhage. A unilateral headache that improves by sitting upright or standing is an intervention for this syndrome. Difficulty breathing is an indication of an incisional hematoma. A drop in blood pressure is an indication of postoperative hypotension. A change in vision in one eye could indicate the development of a stroke.
Which is a modifiable risk factor for transient ischemic attacks and ischemic strokes? Advanced age Thyroid disease Smoking Social drinking
Smoking Explanation: Modifiable risk factors for TIAs and ischemic stroke include hypertension, diabetes, cardiac disease, smoking, and excessive alcohol consumption. Advanced age, gender, and race are nonmodifiable risk factors for stroke.
The nurse is participating in a health fair for stroke prevention. Which will the nurse say is a modifiable risk factor for ischemic stroke? Advanced age Social drinking Thyroid disease Smoking
Smoking Explanation: Modifiable risk factors for transient ischemic attack (TIA) and ischemic stroke include hypertension, type 1 diabetes, cardiac disease, smoking, and chronic alcoholism. Advanced age, gender, and race are nonmodifiable risk factors for stroke.
Which is indicative of a right hemisphere stroke? Slow, cautious behavior Aphasia Spatial-perceptual deficits Altered intellectual ability
Spatial-perceptual deficits Explanation: Clients with right hemisphere stroke exhibit partial perceptual deficits, left visual field deficit, and paralysis with weakness on the left side of the body. Left hemisphere damage causes aphasia; slow, cautious behavior; and altered intellectual ability.
The nurse has just received report on a client in the ED being transferred to the acute stroke unit with a diagnosis of a right hemispheric stroke. Which findings does the nurse understand is indicative of a right hemispheric stroke? Aphasia Slow, cautious behavior Spatial-perceptual deficits Altered intellectual ability
Spatial-perceptual deficits Explanation: Clients with right hemispheric stroke exhibit partial perceptual deficits, left visual field deficit, and paralysis with weakness on the left side of the body. Left hemispheric damage causes aphasia, slow, cautious behavior, and altered intellectual ability.
What nursing intervention is appropriate for a client with receptive aphasia? Speak slowly and clearly. Explore the client's ability to write. Frequently reorient the client to time, place, and situation. Encourage the client to repeat sounds of the alphabet.
Speak slowly and clearly. Explanation: Nursing management of the client with receptive aphasia includes speaking slowing and clearly to assist the client in forming the sounds. Nursing management of the client with expressive aphasia includes encouraging the client to repeat sounds of the alphabet or to explore the client's ability to write. Nursing management of the client with cognitive deficits, such as memory loss, includes frequently reorienting the client to time, place, and situation.
A client who has experienced an initial transient ischemic attack (TIA) states: "I'm glad it wasn't anything serious." Which is the best nursing response to this statement? "TIA is a warning sign. Let's talk about lowering your risks." "TIA symptoms are short-lived and resolve within 24 hours". "People who experience a TIA will develop a stroke". "I sense that you are happy it was not a stroke".
TIA is a warning sign. Let's talk about lowering your risks." Explanation: TIA is a warning sign and can be used to empower clients to make life changes to lower the risks. Sensing the client is happy is a psychotherapeutic response but does not lead to teaching and learning for health promotion. TIAs can lead to a stroke for approximately one third of the clients but is not a definitive result and presents as a frightening statement without empowering change. TIA symptoms are short-lived, but this is a factual statement that does not provide additional information to the client.
A 71-year-old man has made an appointment with his primary care provider at the urging of his wife, who states that he has occasionally had episodes of weakness and slurring of words over the past several weeks. The care provider recognizes the possibility that the man has been experiencing transient ischemic attacks (TIAs). TIAs have which of the following characteristics? TIAs cause symptoms that last less than 1 hour. TIAs result in motor symptoms rather than sensory symptoms. TIAs cause irreversible, but minor, neurological damage. TIAs are a result of minor cerebral hemorrhages that spontaneously resolve.
TIAs cause symptoms that last less than 1 hour. Explanation: A TIA is defined as a brief episode of neurologic dysfunction caused by focal brain or retinal ischemia, with clinical symptoms typically lasting less than 1 hour, and without evidence of acute infarction. They may cause sensory symptoms and are not a result of hemorrhage.
The nurse is caring for a client with chronic migraines who is prescribed medication. What drug-related instructions should the nurse give the client? Take medication only during the morning when it's calm and quiet. Take medication only when migraine is intense. Take medication as soon as symptoms of the migraine begin. Take medication just before going to bed at night.
Take medication as soon as symptoms of the migraine begin. Explanation: The nurse reinforces the drug therapy regimen and instructs the client on self-administration of medications. To stop the migraine headache, the nurse stresses the importance of taking medication as soon as symptoms of the migraine begin and not when the migraine intensifies.
A client who's paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis? The client repositions only after being reminded to do so. The client uses a mirror to inspect the skin. The client leaves the side rails down. The client hangs the left arm over the side of the wheelchair.
The client uses a mirror to inspect the skin. Explanation: The client demonstrates understanding of safety measures related to paralysis when he uses a mirror to inspect his skin. The mirror enables the client to inspect all areas of the skin for signs of breakdown without the help of staff or family members. The client should keep the side rails up to help with repositioning and to prevent falls. The paralyzed client should take responsibility for repositioning or for reminding the staff to assist with it, if needed. A client with left-side paralysis may not realize that the left arm is hanging over the side of the wheelchair. However, the nurse should call this position to the client's attention because the arm can get caught in the wheel spokes or develop impaired circulation from being in a dependent position for too long.
A community health nurse is conducting a workshop for unlicensed care providers who work in a chain of long-term care facilities. The nurse is teaching the participants about the signs and symptoms of stroke. What signs and symptoms should the nurse identify? Select all that apply. Confusion Epistaxis (nosebleed) Sudden numbness Sudden ear pain Visual disturbances
The most common symptoms of stroke include numbness or weakness of the face, arm, or leg, especially on one side of the body; confusion or change in mental status; trouble speaking or understanding speech; visual disturbances; difficulty walking, dizziness, or loss of balance or coordination; and sudden, severe headache.
A patient has severe shoulder pain from subluxation of the shoulder is being cared for on the unit. To prevent further injury and pain, the nurse caring for this patient is aware of what? Use of a sling should be avoided due to adduction of the affected shoulder. Elevation of the arm and hand can lead to further complications associated with edema. Passively exercising the affected extremity is avoided to minimize pain. The patient should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder.
The patient should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder. Explanation: To prevent shoulder pain, the nurse should never lift a patient by the flaccid shoulder or pull on the affected arm or shoulder. The patient is taught how to move and exercise the affected arm/shoulder through proper movement and positioning. The use of a properly worn sling when the patient is out of bed prevents the paralyzed upper extremity from dangling without support. Range of motion exercises are still vitally important in preventing a frozen shoulder and ultimate atrophy of subcutaneous tissues, which can cause more pain. Elevation of the arm and hand is also important in preventing dependent edema of the hand.
A woman has been brought to the emergency department (ED) by her distraught husband who believes that she has had a stroke. A rapid assessment by the care team confirms that the husband's suspicions are likely accurate, and the woman is being screened for the possible administration of recombinant tissue plasminogen activator (r tPA). Which of the following factors would contraindicate the use of tPA? The woman has previously had a stroke. The woman has hypertension and type 1 diabetes. The woman is older than 80 years of age. The woman's stroke has a hemorrhagic etiology.
The woman's stroke has a hemorrhagic etiology. Explanation: tPA is contraindicated in hemorrhagic stroke because it would greatly exacerbate cerebral bleeding. Older age, previous stroke, hypertension, and diabetes do not necessarily contraindicate the use of tPA.
A patient having an acute stroke with no other significant medical disorders has a blood glucose level of 420 mg/dL. What significance does the hyperglycemia have for this patient? The patient has developed diabetes insipidus due to the location of the stroke. This is significant for poor neurologic outcomes. The patient has new onset diabetes. The patient has liver failure.
This is significant for poor neurologic outcomes. Explanation: Hyperglycemia has been associated with poor neurologic outcomes in acute stroke and should be treated if the blood glucose is above 140 mg/dL (Summers et al., 2009).
An emergency department nurse is awaiting the arrival of a client with signs of an ischemic stroke that began 1 hour ago, as reported by emergency medical personnel. The treatment window for thrombolytic therapy is which of the following? Two hours Three hours Six hours One hour
Three hours Explanation: Rapid diagnosis of stroke and initiation of thrombolytic therapy (within 3 hours) in clients with ischemic stroke leads to a decrease in the size of the stroke and an overall improvement in functional outcome after 3 months.
A client is hospitalized when presenting to the emergency department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to his presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what? Right-sided stroke Cerebral aneurysm Transient ischemic attack Left-sided stroke
Transient ischemic attack Explanation: A transient ischemic attack (TIA) is a sudden, brief attack of neurologic impairment caused by a temporary interruption in cerebral blood flow. Symptoms may disappear within 1 hour; some continue for as long as 1 day. When the symptoms terminate, the client resumes his or her presymptomatic state. The symptoms do not describe a left- or right-sided stroke or a cerebral aneurysm
The nurse is providing information about strokes to a community group. Which of the following would the nurse identify as the primary initial symptoms of an ischemic stroke? Severe headache and early change in level of consciousness Weakness on one side of the body and difficulty with speech Foot drop and external hip rotation Vomiting and seizures
Weakness on one side of the body and difficulty with speech Explanation: The main presenting symptoms for an ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body; confusion or change in mental status; and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Foot drop and external hip rotation are things that can occur if a stroke victim is not turned or positioned correctly.
A client diagnosed with a stroke is ordered to receive warfarin. Later, the nurse learns that the warfarin is contraindicated and the order is canceled. The nurse knows that the best alternative medication to give is ticlopidine. dipyridamole. aspirin. clopidogrel.
aspirin. Explanation: If warfarin is contraindicated, aspirin is the best option, although other medications may be used if both are contraindicated.
A nurse is reading a journal article about stroke and the underlying causes associated with this condition. The nurse demonstrates understanding of the information when identifying which subtype of stroke as being due to atrial fibrillation? small, penetrating artery thrombotic cardio embolic cryptogenic large-artery thrombotic
cardio embolic Explanation: Ischemic strokes are further divided into five subtypes, according to a mechanism-based classification system: large-artery thrombotic strokes (representing 20% of ischemic strokes); small, penetrating artery thrombotic strokes (25%); cardio embolic strokes (20%); cryptogenic strokes (strokes that cannot be attributed to any specific cause) (30%); and "other" (5%). Large-artery thrombotic strokes are caused by atherosclerotic plaques in the large blood vessels of the brain. Thrombus formation and occlusion can occur at the site of the atherosclerosis and result in ischemia and infarction (tissue death). Small, penetrating artery thrombotic strokes that affect one or more vessels and cause reduced blood flow are the most common type of ischemic stroke, typically caused by longstanding hypertension, hyperlipidemia, or diabetes. Cardio embolic strokes are associated with cardiac dysrhythmias, such as atrial fibrillation, but can also be associated with valvular heart disease or left ventricular thrombus. The last two classifications of ischemic strokes are cryptogenic strokes, which have no identified cause, and strokes from other causes, such as illicit drug use (cocaine), coagulopathies, migraine, or spontaneous dissection of the carotid or vertebral arteries.
A client diagnosed with a stroke is having difficulty forming words during communication. This would be appropriately documented as diplopia. dysphagia. dysarthria. receptive aphasia.
dysarthria. Explanation: Dysarthria is difficulty in forming words. Dysphagia is difficulty swallowing. Receptive aphasia is the inability to comprehend the spoken word. Diplopia is double vision.
A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the health care provider in the emergency department. Which is the origin of the client's symptoms? impaired cerebral circulation cardiac disease hypertension diabetes insipidus
impaired cerebral circulation Explanation: TIAs involve the same mechanism as in the ischemic cascade, but symptoms are transient (< 24 hours) and there is no evidence of cerebral tissue infarction. The ischemic cascade begins when cerebral blood flow decreases to less than 25 mL/100 g/min and neurons are no longer able to maintain aerobic respiration. Thus, a TIA results directly from impaired blood circulation in the brain. Atherosclerosis, cardiac disease, hypertension, or diabetes can be risk factors for a TIA but do not cause it.
