Evolve - Stroke Management

The registered nurse is teaching a student nurse about airway management for a patient who is at risk of aspiration. Which statement made by the student nurse indicates effective learning?

"I will perform suctioning as needed."

What behavior is exhibited by a patient who has suffered a right-brain stroke?

Impulsive and impatient

The nurse uses appropriate delegation of assignments when instructing the experienced unlicensed assistive personnel (UAP) to do what?

Perform passive range of motion to flaccid extremities

During assessment of a female patient who has experienced a stroke, the nurse notes certain findings. What are the findings that could be associated with the stroke?

The patient is on oral contraceptives. The patient has a history of migraine with aura.

A lumbar puncture is to be performed for a patient with suspected subarachnoid hemorrhage. What should the nurse tell the patient about this procedure?

"It has been advised so we can look for evidence of red blood cells in the cerebrospinal fluid." "It has been ordered because the computed tomographic (CT) scan does not show hemorrhage."

A nurse is admitting a patient with a thrombotic stroke. The patient is nothing by mouth (NPO) but is requesting a drink of water. Which response by a nurse is appropriate?

"It is not safe to allow you to have anything by mouth until a swallow assessment can be performed."

The registered nurse is teaching a student nurse about acute care for a patient with ischemic stroke. The patient's blood pressure is 230/120 mm Hg. Which statement made by the student nurse indicates the need for further teaching?

"Large amounts of fluid should be provided."

A registered nurse is teaching a student nurse about the management of increased intracranial pressure in a patient who sustained a stroke. Which statement made by the student nurse indicates the need for further teaching?

"The patient should be placed in a supine position."

A patient is admitted to the emergency department with right-sided facial drooping. When taking the patient's history, which information would be most significant?

"When did the facial drooping begin?"

A registered nurse is teaching a student nurse about tissue plasminogen activator (tPA) administration in a patient with ischemic stroke. Which statement made by the student nurse indicates a need for further teaching?

"tPA should be administered within 12 hours of the onset of a stroke."

A patient presenting with stroke symptoms is being considered for fibrinolytic therapy. What assessment data would be important to communicate promptly to the prescribing health care provider?

Colonoscopy for evaluation of blood in the stools one week ago

Immediately after a stroke, the nurse takes the blood pressure (BP) of the patient and finds it to be 80/60 mm Hg. What should be the plan of action of the nurse for this finding?

Correct hypotension. Correct hypovolemia. Continue treatment for stroke.

The nurse is feeding a patient by mouth for the first time after a stroke. What should the nurse feed the patient at this first feeding?

Crushed ice

Which action can the nurse delegate to the unlicensed assistive personnel (UAP) to reduce fatigue for a patient recovering from a stroke at meal times?

Cut up the meat for the patient.

A patient who had a stroke three days ago has constipation. What should be the first interventions?

Encourage physical activity. Encourage fluid and fiber intake.

A nurse assesses the blood pressure (BP) of a patient who had a stroke and finds it to be 166/96 mm Hg. What is the priority action by the nurse?

Ensure adequate fluid intake Consider this as a protective response

A patient is scheduled for a serial computed tomography (CT) scan after a stroke. What should the nurse tell the patient and the patient's relatives about this procedure?

It helps to evaluate recovery. It helps to assess the effectiveness of treatment.

During the acute phase of stroke management, the most important nursing intervention to decrease risk of aspiration is what?

Maintaining nothing by mouth (NPO) status

A patient has been given an intraarterial infusion of tissue plasminogen activator (tPA) for ischemic stroke. What are the responsibilities of the nurse for 24 hours post treatment?

Monitor VS Check BP

A patient is admitted to the hospital with a stroke. Which interventions should be included in the acute care of a stroke patient?

Monitor urine output. Monitor the blood sugar level. Ensure adequate fluid intake.

A patient with a hemorrhagic stroke has a decreased level of consciousness and an altered swallowing reflex. What is an appropriate nursing intervention?

Providing small amounts of food

What action is most beneficial to a patient with a right-brain stroke?

Remove clutter and obstacles

While assessing a patient who sustained a hemorrhagic stroke, the nurse finds that the patient has decreased gag, cough, and swallowing reflexes. Which complication should the nurse expect in the patient?

Risk of aspiration

A patient who had a transient ischemic attack (TIA) is being discharged home from the hospital. What patient teaching should the nurse perform before discharge?

Smoking cessation decreases risk of a stroke. Hypertension is the most important modifiable stroke risk factor.

A patient who has had a stroke is frustrated by mobility problems. What should the nurse do?

Allow family and friends to visit the patient more often. Speak to the patient in a calm, caring manner to reduce frustration. Help the family understand that frustration is common in the first year after a stroke.

A patient has left-sided hemiplegia following an ischemic stroke that was experienced four days earlier. How should the nurse best promote the health of the patient's integumentary system?

Alternate the patient's positioning between supine and side-lying.

A patient is being discharged from the hospital after recovering from stroke. What food items should be included in the diet plan?

Grilled chicken Vegetable soups

What precautions should the nurse follow when feeding a patient with a stroke on the left side?

Place the patient in high Fowler's position. Place the patient in a chair with the head flexed forward.

A patient underwent aneurysm clipping six hours ago for subarachnoid hemorrhage and is being treated with nimodipine. While examining the patient, the nurse finds that the pulse of the patient is 50 beats per minute (beats/minute) and the blood pressure is 90/60 mm Hg. What should the nurse do?

Hold the medication and contact the primary health care provider.

The nurse is caring for a patient after a cerebrovascular accident. During assessment, the nurse notes adventitious breath sounds and the accumulation of sputum. Why does the nurse encourage the patient to take slow, deep breaths and to cough frequently?

To increase airway clearance

The nurse is providing education on the drug clopidogrel for a patient who experienced a transient ischemic attack (TIA). Which patient statement indicates a need for further teaching?

"I need to keep in close contact with my health care provider because I need frequent blood tests to adjust the medication dose."

The nurse is teaching a student nurse about implementing a bladder retraining program for a patient who sustained a hemorrhagic stroke. Which statement made by the student nurse indicates the need for further teaching?

"I will provide an adequate amount of fluid to the patient between 5:00 AM and 9:00 PM."

The registered nurse is teaching a student nurse about the proper way to communicate with a patient who has aphasia due to a stroke. Which statement made by the student nurse indicates a need for further learning?

"I will try to force communication with the patient if the patient is upset."

A relative of a stroke patient who is unable to walk is not sure about the benefits of mirror therapy. How will the nurse assure the relative?

"Mirror therapy may improve the patient's ability to walk." "Mirror therapy is an additional intervention along with other treatments."

A patient has experienced a right-brain stroke. What intervention would be most important to include in the plan of care?

Evaluate body positioning during all transfers.

What should be included in the nursing plan for prevention of skin breakdown in a stroke patient?

Good skin hygiene Applying emollients to dry skin

A computed tomography (CT) scan of the head of a patient reveals that the patient has experienced a hemorrhagic stroke. What is the priority nursing intervention in the emergency department?

Maintenance of the patient's airway

A nurse is caring for a patient who had a stroke and is at risk of venous thromboembolism (VTE). What should be included in the nursing interventions for such patients?

Note unusual warmth of legs. Measure the calf and thigh daily. Observe swelling of lower extremities.

The patient with diabetes mellitus has had a right-hemispheric stroke. Which nursing intervention should the nurse plan to provide for this patient related to expected manifestations of this stroke?

Safety measures

A novice nurse is developing a care plan for impaired swallowing in a patient after a stroke. Which outcome included by the nurse requires revision?

The patient is able to chew well.

The nurse plans care for a patient who has had a stroke and is experiencing residual expressive aphasia. What is an appropriate expected outcome to be included in the plan?

The patient will demonstrate alternative communication techniques.

What would be the appropriate nursing intervention for optimizing musculoskeletal function of a patient with hemorrhagic stroke?

Discouraging pulling the patient's arm

A patient presents to the emergency department reporting a sudden onset of headache described as "the worse headache ever." The patient also reports nausea and visual disturbances. What collaborative intervention is a priority for the nurse?

Prepare patient for transport to computed tomography (CT) scan.

A patient who has been diagnosed with stroke is complaining of difficulty in movement of the joints. What should the nurse do?

Promote exercises. Provide hand splints.

The nurse is caring for a patient with right-brain stroke. How will the nurse care for this patient in coping with perceptual deficits?

Provide good lighting. Break tasks into simple steps. Provide nonslip socks at all times.

The nurse is planning psychosocial support for the patient and family of the patient who suffered a stroke. What factor most likely will have the greatest impact on positive family coping with the situation?

Rehabilitation potential of the patient

A nurse is formulating a discharge teaching plan for a patient who had a stroke 15 days ago. What instructions should the nurse include in the plan?

Seek spiritual assistance. Maintain adequate fluid intake. Follow-up for rehabilitation therapy is important.

The nurse includes video games in the plan of care for a patient who sustained a stroke. What is the rationale for this intervention?

The patient's motor skills can be improved.

To enhance communication with a patient who has aphasia following a stroke, which communication technique is best for the nurse to use?

Use gestures or demonstrations as indicated.

A patient diagnosed with atrial fibrillation has been put on the oral anticoagulant warfarin. What instructions should the nurse give the patient?

"The drug requires close monitoring." "Do not stop the drug without informing the doctor."

In planning care of a patient with an acute stroke, which intervention would be appropriate for a nurse to delegate to a licensed practical/vocational nurse (LPN/LVN)?

Administer subcutaneous enoxaparin.

During the acute stage of a stroke, it is important for the nurse to include which intervention for a patient experiencing aphasia?

Ask simple yes and no questions.

While assessing a patient with paralysis due to a hemorrhagic stroke, the registered nurse finds redness of the patient's skin. What would be the most appropriate intervention to prevent complications in the patient?

Changing the patient's position

A patient with hemorrhagic stroke has undergone aneurysmal occlusion via clipping and has a blood pressure of 90/60 mm Hg. What should be included in postoperative care of the patient?

Start dopamine (Inotropin). Encourage fluid intake. Start crystalloid solution to achieve volume expansion.

A nurse is measuring the blood pressure of a hypertensive obese patient who has been admitted to the hospital for increased blood glucose levels. While they are speaking, the nurse notes that the patient has suddenly started mumbling and is unable to articulate words. What is the nurse's priority action?

Treat this as an emergency and call the health care provider.

The nurse is discharging a patient admitted with a transient ischemic attack (TIA). For which medications might the nurse expect to provide discharge instructions?

Clopidogrel Enoxaparin Dipyridamole Enteric-coated aspirin

A patient is admitted with a hemorrhagic stroke. Which prescription should a nurse question?

Clopidogrel 75 mg by mouth (PO) once daily

A nurse is screening patients to determine if administering tissue plasminogen activator (tPA) for fibrinolytic therapy is an appropriate intervention. Which patients may be administered tPA safely?

A 70-year-old with blood sugar levels of 110 mg/dL A 40-year-old with history of head injury six months ago A 25-year-old with history of cholecystectomy two years previously

A registered nurse is caring for a patient who suffered a stroke one day ago. What is the responsibility of the nurse in caring for this patient?

Assess neurologic status. Assess respiratory status.

A patient has suffered a right-brain stroke. What should the nurse include in the safety measures immediately after the stroke?

Avoid using vests. Elevate the side rails. Use video monitors to observe the patient continuously.

A patient is diagnosed with a transient ischemic attack due to carotid artery disease. Which surgical procedure would the primary health care provider suggest for this patient, as depicted in the image?

Carotid endarterectomy

A nurse is caring for stroke patients. What should the nurse include in the bladder retraining program of a stroke-affected patient?

Encourage adequate fluid intake. Observe for signs of restlessness. Assess bladder distention by palpation.

Which are primary methods of preventing a stroke?

Healthy diet Regular exercise Management of blood pressure

A nurse is delegating responsibilities to unlicensed assistive personnel for caring for a patient who has suffered from a stroke this morning. What responsibilities will the nurse assign?

Measure and record urine output Perform passive and active range-of-motion exercises

A patient with known history of hypertension presents to the emergency department with the complaint of sudden severe headache with no known cause. What should the nurse do first?

Obtain a computed tomographic (CT) scan.

A nurse is caring for a patient who is not able to swallow properly post stroke. What interventions are important to facilitate patient safety during eating?

Place food on the unaffected side of the mouth. Check mouth for pocketing of food. Help the patient maintain a sitting position for 30 minutes after a completing meal.

When planning for venous thromboembolism (VTE) prevention, what should the nurse place as the highest priority ?

Active and passive range-of-motion (ROM) exercises.

The primary health care provider has prescribed nimodipine. Which nursing action is appropriate?

Administer if heart rate is greater than 60 beats/minute.

The nurse assesses a patient experiencing visual disturbances and difficulty swallowing with a blood pressure of 280/180 mm Hg. What is the priority action by the nurse when the patient loses consciousness?

Ensure patent airway.

A patient with a history of transient ischemic attack has been prescribed aspirin at a dose of 81 mg/day. What information about aspirin should be given to the patient?

It may cause tinnitus, which should be reported immediately. It may cause bleeding, which should be reported immediately.

The relatives of a patient suspected of having a stroke are concerned, because the doctor has asked the patient to undergo magnetic resonance imaging (MRI). What information will be included when explaining to the relatives the importance of undergoing MRI? multiple selection

MRI helps to identify the likely causes of stroke. MRI helps to differentiate between a stroke and any other brain lesion.

A nurse is caring for a patient who has aphasia after suffering from a stroke. How will the nurse communicate with the patient?

Make use of gestures. Present only one thought at a time. Do not interrupt the patient if he or she is taking too long to communicate.