Chapter 47
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?
15 to 20 mL/100 g/min
A nurse knows that, for a patient with an ischemic stroke, tPA is contraindicated if the blood pressure reading is:
190 mm Hg/120 mm Hg
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?
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:
8 mL/100 g/min
Which term refers to the failure to recognize familiar objects perceived by the senses?
Agnosia
A nurse is caring for a client who has returned to his room after a carotid endarterectomy. Which action should the nurse take first?
Ask the client if he has trouble breathing.
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
Aspirin
Which of the following is the most common side effect of tissue plasminogen activator (tPA)?
Bleeding
The nurse is discharging home a patient who suffered a stroke. The patient has a flaccid right arm and leg and is experiencing problems with urinary incontinence. The nurse makes a referral to the home health nurse because the hospital nurse is aware that the most common patient response to a change in body image is what?
Depression
A patient admitted with a stroke is coming to the unit from the emergency department. The nurse assigned to care for the new patient knows that what assessment finding is indicative of a stroke?
Difficulty speaking
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
From which direction should a nurse approach a client who is blind in the right eye?
From the left side of the client
A stroke victim is experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe?
Frontal
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:
Hypertension
Which of the following antiseizure medication has been found to be effective for post-stroke pain?
Lamotrigine (Lamictal)
A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem?
Lioresal (Baclofen)
Which of the following is accurate regarding a hemorrhagic stroke?
Main presenting symptom is an "exploding headache."
The nurse is caring for a client diagnosed with a hemorrhagic stroke. The nurse recognizes that which intervention is most important?
Maintaining a patent airway
Which clinical manifestation would be exhibited by a client following a hemorrhagic stroke of the right hemisphere?
Neglect of the left side
A client is suspected of having had a stroke. Which is the initial diagnostic test for a stroke?
Noncontrast computed tomography
A patient has had an ischemic stroke and has been admitted to the unit. The nurse knows the importance of the principles of body alignment and correct positioning to stroke victims. How should the nurse position the patient to prevent joint deformities?
Place a pillow in the axilla when there is limited external rotation.
The nurse is caring for a client with dysphagia. Which intervention would be contraindicated while caring for this client?
Placing food on the affected side of the mouth
SATA After having a stroke, a patient has cognitive deficits. What are the cognitive deficits the nurse recognizes the patient has as a result of the stroke?
Poor abstract reasoning Decreased attention span Short- and long-term memory loss
SATA The nurse is caring for a client diagnosed with a subarachnoid hemorrhage resulting from a leaking aneurysm. The client is awaiting surgery. Which nursing interventions would be appropriate for the nurse to implement?
Provide a dimly lit environment. Elevate the head of bed 30 degrees. Administer docusate per order
The nurse is providing diet-related advice to a male patient following a cerebrovascular accident (CVA). The patient wants to minimize the volume of food and yet meet all nutritional elements. Which of the following suggestions should the nurse give to the patient about controlling the volume of food intake?
Provide thickened commercial beverages and fortified cooked cereals.
Which set of symptoms characterize Korsakoff syndrome?
Psychosis, disorientation, delirium, insomnia, and hallucinations
SATA The nurse is completing an assessment on a client with a history of migraines. The nurse would identify which of the following factors as a possible trigger for a migraine headache?
Red wine Menstruation Exposure to flashing light
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.
When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke?
The day the patient has the stroke
The nurse is performing stroke risk screenings at a hospital open house. Identification of high-risk individuals is the goal of the screenings. The nurse has identified four patients who might be at risk for a stroke. Which patient is likely at highest risk for a stroke?
White man, age 60 with history of uncontrolled hypertension
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?
cardio embolic
When communicating with a client who has sensory (receptive) aphasia, the nurse should:
use short, simple sentences.
A client with a history of atrial fibrillation has experienced a TIA. In an effort to reduce the risk of cerebrovascular accident (CVA), the nurse anticipates the priority medical treatment to include which of the following?
Anticoagulant therapy
Which term refers to the inability to perform previously learned purposeful motor acts on a voluntary basis?
Apraxia
A 45-year-old client presents to the ED reporting trouble speaking and numbness of the right arm and leg. The nurse suspects an ischemic stroke. Which insult or abnormality can cause an ischemic stroke?
Cocaine use
SATA 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?
Confusion Sudden numbness Visual disturbances
During assessment of cognitive impairment, post-stroke, the nurse documents that the patient was experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe?
Frontal
A client is receiving an IV infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant?
Increased urine output
The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient?
Semi Fowlers
While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are:
Severe headache and early change in level of consciousness
The nurse is participating in a health fair for stroke prevention. Which will the nurse say is a modifiable risk factor for ischemic stroke?
Smoking
Which is a modifiable risk factor for transient ischemic attacks and ischemic strokes?
Smoking
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?
Transient ischemic attack
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?
Alteration in LOC
SATA Which interventions would be recommended for a client with dysphagia?
Assist the client with meals. Test the gag reflex before offering food or fluids. Allow ample time to eat.
Which of the following, if left untreated, can lead to an ischemic stroke?
Atrial fibrillation
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
A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question?
Heparin sodium
Which disturbance results in loss of half of the visual field?
Homonymous hemianopsia
Which terms refers to blindness in the right or left half of the visual field in both eyes?
Homonymous hemianopsia
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?
Keeping the client in one position to decrease bleeding
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's stroke has a hemorrhagic etiology.
A patient is exhibiting classic signs of a hemorrhagic stroke. What complaint from the patient would be an indicator of this type of stroke?
severe headache
While the nurse is making initial rounds after coming on shift, you find a client thrashing about in bed complaining of a severe headache. The client tells the nurse the pain is behind the right eye, which is red and tearing. What type of headache would the nurse suspect this client of having?
Cluster
The nurse is caring for a client with aphasia. Which strategy will the nurse use to facilitate communication with the client?
Establishing eye contact
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?
Lack of deep tendon reflexes
Health promotion efforts to decrease the risk for ischemic stroke involve encouraging a healthy lifestyle including
a low-fat, low-cholesterol diet and increased exercise.
The nurse is preparing to administer tissue plasminogen activator (t-PA) to a patient who weighs 132 lb. The order reads 0.9 mg/kg t-PA. The nurse understands that 10% of the calculated dose is administered as an IV bolus over 1 minute, and the remaining dose (90%) is administered IV over 1 hour via an infusion pump. How many milligrams IV bolus over 1 minute will the nurse initially administer?
5.4
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?
Auditory
Which of the following is the initial diagnostic in suspected stroke?
Noncontrast computed tomography (CT)
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?
Restrict fluids before surgery