Chapter 49. Nursing Care of Patients With Cerebrovascular Disorders

The nurse is aware that children can be at risk for an embolic stroke. Which condition is least likely to cause a child to have a stroke? 1. Contact sport trauma 2. Sickle cell disease 3. Hyperlipidemia 4. Congenital heart defect

1. Contact sport trauma Contact sport trauma is the least likely cause of an embolic stroke, given the other more likely causes.

The nurse is assisting the registered nurse (RN) in providing care for a patient who is recovering from a stroke. Which assigned intervention by the RN will the nurse question? 1. Observe the patient performing active range of motion (ROM) on the affected side. 2. Assist with maintaining correct body alignment for comfort. 3. Support affected extremities with pillows to prevent dislocation. 4. Follow the physical therapist's (PT's) recommendations for being up in a bedside chair.

1. Observe the patient performing active range of motion (ROM) on the affected side. The patient is not likely to be able to perform active ROM on the affected side following a stroke. The nurse will seek clarification from the RN.

A patient is recovering from a stroke. The family reports to the nurse that the patient alternates between periods of crying for no given reason to periods of laughing inappropriately. Which condition does the nurse suspect the patient is exhibiting? 1. Pseudobulbar effect 2. Psychotic events 3. Bipolar disorder 4. Mood swings

1. Pseudobulbar effect A common consequence of a stroke is pseudobulbar effect in which the patient exhibits emotional lability or instability. Patients move between periods of profound sadness to euphoria and back again. Treatment is with the medication dextromethorphan quinidine.

A patient arrives in the emergency department at 0200 exhibiting the manifestations of a stroke. The patient reports going to bed at 2100 and being negative for symptoms. If the CT reveals an ischemic stroke related to a blood clot, for which reason is tPA therapy withheld? 1. The therapy is based on the time the patient went to bed. 2. The patient's symptoms have progressed too quickly. 3. The total effects of ischemia are not currently known. 4. The patient is negative for any symptoms related to intracranial pressure (ICP).

1. The therapy is based on the time the patient went to bed. When a patient awakens during the night with symptoms of a stroke, the time of the stroke is set at the time the patient went to bed. Thrombolytic therapy must be started within 3 to 4.5 hours of symptom onset to be most effective.

A patient began experiencing manifestations of a stroke at 0800 hours. By which time should thrombolytic medications be provided to reverse stroke symptoms? 1. 0900 hours 2. 1250 hours 3. 1400 hours 4. 1660 hours

2. 1250 hours If a patient experiencing ischemic stroke symptoms receives treatment within 4.5 hours of symptom onset, medication can be provided to resolve the deficits.

A patient arrives at the emergency department and states, "Something is wrong. I just don't feel right." Which objective data causes the nurse to suspect the patient is experiencing some type of stroke? 1. Symptoms have been increasing in severity for several days. 2. Ataxia is present when the patient attempts to ambulate. 3. The patient was diagnosed with hypertension managed with medication. 4. The patient appears upset and cries easily throughout assessment.

2. Ataxia is present when the patient attempts to ambulate. Ataxia may occur with a stroke and includes poor balance or stumbling, and a staggering gate. This data is objective and strongly related to a stroke.

A patient is admitted from the emergency department to the hospital unit following the diagnosis of an ischemic stroke. The patient did not qualify for tPA therapy. The nurse is aware that which poststroke condition places the patient at greatest risk for deep vein thrombosis (DVT)? 1. The inability to be mobile and move independently 2. Hypercoagulability related to the admitting diagnosis 3. Testing that identified the cause of the stroke as ischemic 4. Laboratory tests indicating hyperlipidemia with high-density lipoprotein (HDL) at 200

2. Hypercoagulability related to the admitting diagnosis When an ischemic stroke occurs, it is commonly from a blood clot, a condition complicated by the inability for tPA therapy. Therefore, the patient is at greatest risk for DVT due to the hypercoagulability of the blood.

The nurse is providing care for a patient with expressive aphasia. Which intervention does the nurse expect to find in the patient's plan of care? (Select all that apply.) (2) 1. Speak loudly. 2. Use a picture board. 3. Obtain an interpreter. 4. Provide pencil and paper. 5. Speak slowly and clearly.

2. Use a picture board. 4. Provide pencil and paper. For expressive aphasia, pencil and paper or a picture board can help with communication. For expressive aphasia, pencil and paper or a picture board can help with communication.

The nurse is providing care for a patient diagnosed with a cerebral aneurysm and subarachnoid hemorrhage. Which statement by the patient indicates a need for additional information? 1. "The doctors are going to do studies to see if I can have surgery." 2. "I know that I will be on some restrictions to prevent a rebleed." 3. "No strenuous activity until this condition is cured by surgery." 4. "It is very important to take my blood pressure medicine."

3. "No strenuous activity until this condition is cured by surgery." As stated above, restrictions are expected; however, the patient needs additional information about the prospect of curing the condition. Subarachnoid hemorrhage is not curable; treatment consists of stabilizing the cause if possible and preventing or managing complications.

The nurse is preparing to assist a patient with eating who is recovering from a stroke. Which intervention is appropriate? 1. Have the patient sip liquids in small amounts with a straw. 2. Place the patient in a semi-Fowler's position to promote swallowing. 3. Check the patient's mouth periodically for presence of pocketed food. 4. Instruct the patient to swallow numerous times to clear food from the mouth.

3. Check the patient's mouth periodically for presence of pocketed food. The nurse checks the patient's mouth periodically for pocketed food, which commonly occurs in patients with swallowing issues.

The nurse is providing care for a patient diagnosed with an ischemic stroke on the left side of the brain. The nurse notices that the patient does not easily locate items placed at the bedside. In which area does the nurse place items for easy location? 1. On the left side 2. Directly in front 3. One the right side 4. As the patient wants

3. One the right side The patient with a stroke on the left side will have vision in the right eye. Items should be place on the right side.

The nurse is assisting with the care of a patient following an ischemic stroke who does not qualify for tPA therapy. The patient's current blood pressure is 190/110 mm Hg. For which reason will the patient's hypertension remain untreated? 1. The elevated blood pressure will create collateral circulation in the brain. 2. Therapeutic blood pressure needs to exceed 220/120 mm Hg to be effective. 3. Permissive hypertension is being therapeutically used to salvage brain tissue. 4. Hypertension will move the clot to an area of the brain treatable by tPA.

3. Permissive hypertension is being therapeutically used to salvage brain tissue. Permissive hypertension is used when the patient does not qualify for tPA therapy to improve cerebral circulation.

A patient comes into the emergency department with unilateral paralysis, aphasia, and inability to follow directions. Which emergency management by the health care provider (HCP) is unexpected by the nurse? 1. Maintenance of oxygen therapy to a saturation of at least 94 percent 2. Careful monitoring of changes in the patient's level of consciousness 3. Scheduling laboratory tests, electrocardiogram (ECG), and computerized tomography (CT) scan to be performed within 45 minutes 4. Immediate treatment for temperature greater than 99.6°F

3. Scheduling laboratory tests, electrocardiogram (ECG), and computerized tomography (CT) scan to be performed within 45 minutes Laboratory tests, ECG, and CT scan are ordered with the expectation that results will be available within 45 minutes of arrival. The HCP will want to make a decision for thrombolytic therapy within an hour of arrival.

The patient is diagnosed with a cerebral vascular accident that has the slowest rate of recovery and the highest probability of causing extensive neurologic deficits. For which type of stroke does the nurse plan care for this patient? 1. Thrombotic stroke 2. Cerebral aneurysm 3. Subarachnoid hemorrhage (SAH) 4. Reversible ischemic neurologic deficit (RIND)

3. Subarachnoid hemorrhage (SAH) SAH is caused by rupture of blood vessels on the surface of the brain. This type of infarct has the slowest rate of recovery and the highest probability of leaving the patient with extensive neurologic deficits.

The nurse is providing care for a patient recovering from a right hemisphere infarct who now exhibits unilateral neglect. Which nursing intervention is most important at promoting safety for this patient? 1. Encourage the patient to turn her plate for ease in self-feeding. 2. Place the call light and phone on the patient's left side. 3. Teach the patient to purposefully check the location of the left limbs. 4. Provide stimuli of all senses on the patient's affected side.

3. Teach the patient to purposefully check the location of the left limbs. Because the patient can be totally unaware of the left side of the body, injury can easily occur from unsafe positioning. The patient needs to check the location of the left limbs. This intervention is most important for promoting safety

The HCP is preparing to discharge a patient from the hospital after a stroke. The patient is insistent on being sent to a rehabilitation center. The nurse is aware that the patient must meet which qualification to go to rehabilitation? 1. The determination to live alone and independently 2. The willingness to commit to long-term therapy 3. The ability to participate in intensive therapy 4. The acceptance of financial responsibility

3. The ability to participate in intensive therapy For a patient to qualify for rehabilitation after a stroke, the patient must have the ability to participate in intensive therapy.

The nurse is involved in a blood pressure clinic in the community, and an individual with possible stroke symptoms is brought for evaluation. Which findings in the FAST (Face, Arms, Speech, and Time) assessment indicate the need to call emergency personnel? (Select all that apply.) (3) 1. The patient sways when asked to stand still with eyes closed. 2. The patient is unable to follow directions during the assessment. 3. The patient is unable to repeat a stated phrase exactly as it was stated. 4. The patient's face shows signs of uneven symmetry when asked to smile. 5. When asked to close the eyes and hold arms straight in front, one arm drifts

3. The patient is unable to repeat a stated phrase exactly as it was stated. 4. The patient's face shows signs of uneven symmetry when asked to smile. 5. When asked to close the eyes and hold arms straight in front, one arm drifts The acronym FAST can help identify a stroke. Ask the person to say, "It is a bright and sunny day." Any difficulty understanding or speaking is abnormal. Call 911 immediately for any abnormal findings. The acronym FAST can help identify a stroke. Ask the person to smile. If the face droops or is uneven on one side, it is abnormal. Call 911 immediately for any abnormal findings. The acronym FAST can help identify a stroke. Ask the person to close his or her eyes and hold the arms out in front of him or her. If an arm cannot be raised or drifts downward, it is abnormal. Call 911 immediately for any abnormal findings.

The nurse is reviewing the medical records of patients in an HCP's practice. Which patient does the nurse recognize as the greatest risk for a stroke? 1. A postmenopausal patient who has type 2 diabetes mellitus (DM) controlled by diet 2. An overweight male with a 15-year smoking history, who is treated for hypertension 3. A young adult born with a heart defect causing ventricle fibrillation 4. An older female patient who has osteoporosis, a femur fracture, and hyperlipidemia

4. An older female patient who has osteoporosis, a femur fracture, and hyperlipidemia The older female patient has five risks for a stroke: gender, age, fracture of a large bone, high cholesterol, and decreased activity related to a fractured femur

The nurse is providing care for a patient diagnosed with a stroke resulting in language disorder. Which type of disorder does the nurse recognize if the patient raises an arm in response to the nurse's direction to stick out his tongue? 1. Dysarthria 2. Expressive aphasia 3. Dysphasia 4. Receptive aphasia

4. Receptive aphasia The patient has receptive aphasia, which is the inability to understand spoken and/or written words.

A patient comes into the emergency department with symptoms of a stroke. Which medication does the nurse expect to be given to the patient if diagnostic testing confirms an ischemic stroke? 1. Heparin 2. Clopidogrel 3. Warfarin 4. Tissue-type plasminogen activator (tPA)

4. Tissue-type plasminogen activator (tPA) tPA is a thrombolytic agent that can break down the thrombus causing the occlusion, which can potentially prevent or completely reverse the symptoms of an ischemic stroke.