Chapter 62: Management of Patients with Cerebrovascular Disorders

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. 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.

Which term refers to the failure to recognize familiar objects perceived by the senses? Agnosia Apraxia Agraphia 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

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 Speak at all Form words that are understandable or comprehend spoken words Comprehend spoken words

Form words that are understandable or comprehend spoken words

A critical care nurse is caring for a client with a cerebrovascular accident (CVA) The client is prescribed heparin for treatment. The nurse knows to monitor the client for what adverse effects? Respiratory distress Migraine attacks Hemorrhage High blood pressure

Hemorrhage

Which of the following is accurate regarding a hemorrhagic stroke? Functional recovery usually plateaus at 6 months. Main presenting symptom is an "exploding headache." One of the main presenting symptoms is numbness or weakness of the face. 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

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 Administering a stool softener Monitoring for seizure activity Elevating the head of the bed to 30 degrees

Maintaining a patent airway

While caring for clients who have suffered neurologic deficits from causes such as cerebrovascular accident and closed head injury, an important nursing goal that motivates nurses to offer the best care possible is preventing: infection. choking. falls. complications.

complications.

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 prescribed medications. Restrict fluids before surgery. Administer preoperative sedation. Administer an osmotic diuretic.

Restrict fluids before surgery. 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.

Which of the following diagnostics are beneficial to detect intracranial stenosis? CT with contrast Magnetic resonance imaging (MRI) Transcranial Doppler (TCD) Computed tomography (CT)

Transcranial Doppler (TCD) Explanation: The transcranial Doppler is useful in detecting severe intracranial stenosis, in evaluating the carotid and vertebrobasilar vessels, in assessing patterns and extent of collateral circulation in patients with known arterial stenosis or occlusion, and in detecting microemboli. A CT, CT with contrast, and MRI would not be beneficial for this purpose.

Which of the following is the most common side effect of tissue plasminogen activator (tPA)? Increased intracranial pressure (ICP) Headache Bleeding Hypertension

BleedingExplanation: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). Headache, increased ICP, and hypertension are not side effects of tPA

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? Cardiogenic emboli Large artery thrombosis Small artery thrombosis Cerebral aneurysm

Cerebral aneurysm A cerebral aneurysm is a type of hemorrhagic stroke that is characterized by an exploding headache.

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? Keeping skin clean and dry Elevating the head of the bed to 30 degrees Performing range-of-motion (ROM) exercises on the left side Checking stools for occult blood

Elevating the head of the bed to 30 degrees

A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to do perform which action? Comprehend spoken words Speak at all Form understandable words and comprehend spoken words Form understandable words

Form understandable words and comprehend spoken words

The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient? Prone Semi-Fowler's Supine High-Fowler's

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.

A diagnostic test has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include thickened liquids. Which of the following is the priority nursing diagnosis for this client? Decreased Fluid Volume Risk Impaired Swallowing Aspiration Risk Malnutrition Risk

Impaired Swallowing Explanation: Impaired Swallowing was evident on the video fluoroscopy. Aspiration, Malnutrition, and Decreased Fluid Volume Risk can occur but are not the primary diagnosis at this point in time.

Which is a contraindication for the administration of tissue plasminogen activator (t-PA)? Ischemic stroke Age 18 years or older Systolic blood pressure less than or equal to 185 mm Hg 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

Which is a modifiable risk factor for transient ischemic attacks and ischemic strokes? Advanced age Thyroid disease Smoking Social drinking

Smoking 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.

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 hangs the left arm over the side of the wheelchair. The client uses a mirror to inspect the skin. The client leaves the side rails down. The client repositions only after being reminded to do so.

The client hangs his left arm over the side of the wheelchair. RATIONALES: Using a mirror enables the client to inspect all areas of his 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 his left arm is hanging over the side of the wheelchair. However, the nurse should call this to the client's attention because his arm can get caught in the wheel spokes or develop impaired circulation from being in a dependent position too long.NURSING PROCESS STEP: EvaluationCLIENT NEEDS CATEGORY: Physiological integrityCLIENT NEEDS SUBCATEGORY: Basic care and comfortCOGNITIVE LEVEL: Application

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? "You sound stressed; maybe using some stress management techniques will help." "You seem upset, and it may be hard for you to focus on the teaching, I'll come back later." "This behavior is common in clients with stroke. Which does your spouse do more often? Laugh or cry?" "Emotional lability is common after a stroke, and it usually improves with time."

"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.

A client is experiencing dysphagia following a stroke. Which measure may be taken by the nurse to ensure that the client's diet allows for easy swallowing? Instruct the client to lie on the bed when eating. Offer liquids frequently and in large quantities. Allow optimum physical activity before meals to expedite digestion. Help the client sit upright when eating and feed slowly.

Help the client sit upright when eating and feed slowly. Having the client sit upright, preferably out of bed in a chair, and instructing him or her to tuck the chin toward the chest when swallowing will help prevent aspiration. The client may be started on a thick liquid or puréed diet, because these foods are easier to swallow than thin liquids. The diet may be advanced as the client becomes more proficient at swallowing. If the client cannot resume oral intake, a gastrointestinal feeding tube is placed for ongoing tube feedings and medication administration. The client should be allowed to rest before meals because fatigue may interfere with coordination and following instructions.

The nurse is caring for a client with aphasia. Which strategy will the nurse use to facilitate communication with the client? Speaking loudly Speaking in complete sentences Avoiding the use of hand gestures Establishing eye contact

Establishing eye contact Explanation:The following strategies should be used by the nurse to encourage communication with a client with aphasia: face the client and establish eye contact, speak in your usual manner and tone, use short phrases, and pause between phrases to allow the client time to understand what is being said; limit conversation to practical and concrete matters; use gestures, pictures, objects, and writing; and as the client uses and handles an object, say what the object is. It helps to match the words with the object or action. Be consistent in using the same words and gestures each time you give instructions or ask a question, and keep extraneous noises and sounds to a minimum. Too much background noise can distract the client or make it difficult to sort out the message being spoken.

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? International normalized ratio greater than 2 Surgery 6 weeks ago Two hour time period of the stroke Taking digoxin

International normalized ratio greater than 2 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.

A nurse knows that, for a patient with an ischemic stroke, tPA is contraindicated if the blood pressure reading is higher than: 170 mm Hg/105 mm Hg 175 mm Hg/100 mm Hg 190 mm Hg/120 mm Hg 185 mm Hg/110 mm Hg

185 mm Hg/110 mm Hg Elevated blood pressure (systolic >185; diastolic >110 mm Hg) is a contraindication to tPA.

Which term refers to the inability to perform previously learned purposeful motor acts on a voluntary basis? Agnosia Agraphia Perseveration Apraxi

Apraxia 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 client is suspected of having had a stroke. Which is the initial diagnostic test for a stroke? Carotid Doppler Transcranial Doppler studies Noncontrast computed tomography Electrocardiography

Noncontrast computed tomography 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 client presents to the ED to determine whether the event is ischemic or hemorrhagic (the category of stroke determines treatment). Further diagnostics include a carotid Doppler, electrocardiogram, and transcranial Doppler.

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 bestalternative medication to give is clopidogrel. aspirin. dipyridamole. ticlopidine.

aspirin

A client's spouse relates how the client reported a severe headache and then was unable to talk or move their right arm and leg. After diagnostics are completed and the client is admitted to the hospital, when would basic rehabilitation begin? after 1 week in 2 to 3 days immediately upon transfer to a rehabilitation unit

immediately

When communicating with a client who has sensory (receptive) aphasia, the nurse should: give the client a writing pad. allow time for the client to respond. use short, simple sentences. speak loudly and articulate clearly.

use short, simple sentences. (Although sensory aphasia allows the client to hear words, it impairs the ability to comprehend their meaning. The nurse should use short, simple sentences to promote comprehension.)

A client reports light-headedness, speech disturbance, and left-sided weakness that have lasted for several hours. In the examination, an abnormal sound is auscultated in an artery leading to the brain. What is the term for the auscultated discovery? bruit diplopia atherosclerotic plaque TIA

Bruit tieng rit A neurologic examination during an attack reveals neurologic deficits. Auscultation of the artery may reveal a bruit (abnormal sound caused by blood flowing over a rough surface within one or both carotid arteries). The term for the auscultated discovery is bruit.

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? Increased urine output Elevated blood pressure Decreased heart rate Decreased level of consciousness (LOC)

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.

A stroke victim is experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe? Occipital Frontal Parietal Temporal

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 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? cardiac disease diabetes insipidus impaired cerebral circulation hypertension

Impaired cerebral circulation TIAs result from impaired blood circulation in the brain, which can be caused by atherosclerosis and arteriosclerosis, cardiac disease, or diabetes. The symptoms of a TIA are the result of impaired blood circulation in the brain, which may have been caused by cardiac disease. The symptoms of a TIA are the result of impaired blood circulation in the brain, which may have been caused by diabetes. The symptoms of a TIA are the result of impaired blood circulation in the brain, which may have been caused by hypertension.

During a class on stroke, a junior nursing student asks what the clinical manifestations of stroke are. What would be the instructor's best answer? "Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation." "Clinical manifestations of a stroke depend on how quickly the clot can be dissolved." "Clinical manifestations of a stroke generally include aphasia, one-sided flaccidity, and trouble swallowing." "Clinical manifestations of a stroke are highly variable, depending on the cardiovascular health of the client."

"Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circu Clinical manifestations following a stroke are highly variable and depend on the area of the cerebral cortex and the affected hemisphere, the degree of blockage (total, partial), and the presence or absence of adequate collateral circulation. (Collateral circulation is circulation formed by smaller blood vessels branching off from or near larger occluded vessels.)

The provider diagnoses the patient as having had an ischemic stroke. The etiology of an ischemic stroke would include which of the following? Intracerebral hemorrhage Cerebral aneurysm Cardiogenic emboli Arteriovenous malformation

Cardiogenic emboli Aneurysms, hemorrhages, and malformations are all examples of a hemorrhagic stroke. An embolism can block blood flow, leading to ischemia.

A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? Dexamethasone Phenytoin Heparin sodium Methyldopa

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 physician may use dexamethasone to decrease cerebral edema and pressure; methyldopa, to reduce blood pressure; and phenytoin, to prevent seizures.

Which of the following is the initial diagnostic in suspected stroke? Magnetic resonance imaging (MRI) CT with contrast Noncontrast computed tomography (CT) Cerebral angiography

Noncontrast computed tomography (CT) An initial head CT scan will determine whether or not the patient is experiencing a hemorrhagic stroke. An ischemic infarction will not be readily visible on initial CT scan if it is performed within the first few hours after symptoms onset; however, evidence of bleeding will almost always be visible.

The nurse is caring for a client following an aneurysm coiling procedure. The nurse documents that the client is experiencing Korsakoff syndrome. Which set of symptoms characterizes Korsakoff syndrome? Severe dementia and myoclonus Psychosis, disorientation, delirium, insomnia, and hallucinations Choreiform movement and dementia Tremor, rigidity, and bradykinesia

Psychosis, disorientation, delirium, insomnia, and hallucinations Advances in technology have led to the introduction of interventional neuroradiology for the treatment of aneurysms. Endovascular techniques may be used in selected clients to occlude the blood flow from the artery that feeds the aneurysm with coils or other techniques to occlude the aneurysm itself. Postoperative complications are rare but can occur. Potential complications include psychological symptoms such as disorientation, amnesia, and Korsakoff syndrome (disorder characterized by psychosis, disorientation, delirium, insomnia, hallucinations, and personality changes). Creutzfeldt-Jakob 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.

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are: Confusion or change in mental status Weakness on one side of the body and difficulty with speech Foot drop and external hip rotation Severe headache and early change in level of consciousness

Severe headache and early change in level of consciousness 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. Footdrop and external hip rotation can occur if a stroke victim is not turned or positioned correctly. (less)

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? Foot drop and external hip rotation Severe headache and early change in level of consciousness Vomiting and seizures Weakness on one side of the body and difficulty with speech

Weakness on one side of the body and difficulty with speech 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. Footdrop and external hip rotation are things that can occur if a stroke victim is not turned or positioned correctly.

Health promotion efforts to decrease the risk for ischemic stroke involve encouraging a healthy lifestyle including a high-protein diet and increased weight-bearing exercise. eating fish no more than once a month. a low-cholesterol, low-protein diet and decreased aerobic exercise. a low-fat, low-cholesterol diet and increased exercise.

a low-fat, low-cholesterol diet and increased exercise. 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. Recent evidence suggests that eating fish two or more times per week reduces the risk of thrombotic stroke for women.