MED/SURG2: Chapter 57

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

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

The nurse is reviewing a patient's chart for factors that may have predisposed the patient to a recent stroke. Which factors placed this patient at risk for the stroke and should be included in the nurse's teaching plan? Select all that apply.

-Atrial fibrillation -Walks once a week -Drinks three glass of red wine daily

The nurse is planning care for a group of patients on a stroke unit. What tasks can the nurse delegate to unlicensed assistive personnel? Select all that apply.

-Measuring and recording oral intake and urine/bowel output -Providing oral and lip care at least every 2 hours and as needed -Placing equipment needed for seizure precautions in the patient's room -Assisting with positioning the patient and turning the patient at least every two hours

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

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

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? Select all that apply.

-Monitor vital signs. -Check blood pressure

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? Select all that apply.

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

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? Select all that apply.

-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? Select all that apply.

-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? Select all that apply.

-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

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? Select all that apply.

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

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? Select all that apply.

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

What precautions should the nurse follow when feeding a patient with a stroke on the left side? Select all that apply.

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

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

-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? Select all that apply.

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

A nurse is planning a community-based stroke awareness/prevention health fair. Which activities would be most helpful to include? Select all that apply.

-Smoking cessation -Cholesterol screening -Blood pressure screening -Early warning signs of a stroke

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? Select all that apply.

-Start dopamine -Encourage fluid intake -Start crystalloid solution

A nurse is teaching a group of caregivers the warning signs of stroke. What type of assessment data obtained from the patients should the nurse teach the caregivers to consider as an emergency? Select all that apply.

-The patient suddenly has blurry vision -The patient suddenly has slurred speech

The patient is being evaluated for thrombolytic therapy. Which findings support the use of thrombolytic agents? Select all that apply.

-There has been no head trauma for three months -The patient's blood pressure (BP) is 180/100 mm Hg -The computed tomographic (CT) scan is clear of hemorrhage

While assessing the level of consciousness in a patient with a stroke, the nurse asks the patient the month and the patient's age. The patient knew his or her age but could not state what month it was. What score should the nurse give to the patient, using the National Institutes of Health Stroke Scale (NIHSS)? Record your answer using a whole number. ___

1

A patient has been admitted to the hospital with acute cerebral infarction. The patient is completely paralyzed on the left side and does not recognize the hand. Other neurologic functions are normal. According to the National Institutes of Health Stroke Scale (NIHSS), what is this patient's score? Record the answer using a whole number. ___

5

The brain requires a continuous supply of blood and oxygen. If it is interrupted, how quickly does cellular death occur?

5 minutes

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

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

A patient has sustained a head injury and is suspected to have increased intracranial pressure. Which factor does the nurse recognize will improve cerebral blood flow?

An increase in hydrogen ion concentration

Which modifiable risk factors for stroke would be most important for the nurse to include when planning a community education program?

Hypertension

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 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.

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

The nurse is preparing a community stroke awareness program. The nurse knows that which ethnic group has the highest incidence of stroke?

African Americans

The nurse finds that the patient is unable to recognize familiar objects after a stroke. What term does the nurse chart in the patient's medical record?

Agnosia

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 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 patient is suspected of having a subarachnoid hemorrhage. For which diagnostic test will the nurse prepare the patient, as the most reliable diagnostic study to identify the source of subarachnoid hemorrhage?

Cerebral angiography

A patient who sustained a stroke is to have a diagnostic test to determine cerebral blood flow. For what diagnostic test does the nurse prepare the patient?

Cerebral angiography

Which mechanism protects the brain and promotes its functioning?

Cerebral autoregulation

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 who sustained a hemorrhagic stroke and has increased intracranial pressure reports to the nurse about loose stools. What is the priority nursing action?

Checking for stool impaction

The patient is scheduled for transluminal angioplasty and stenting. Which drug does the nurse anticipate will be prescribed?

Clopidogrel

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

Clopidogrel 75 mg by mouth (PO) once daily

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

The patient is recovering from a stroke and is confined to bed for most of the day. For which condition is this patient at risk?

Constipation

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.

The nurse would expect to find what clinical manifestation in a patient admitted with a left-hemispheric stroke?

Impaired speech

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

Impulsive and impatient

A patient has sustained a stroke on the right side of the brain. What clinical manifestations does the nurse determine to be associated with this type of injury?

Impulsiveness

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 nurse is preparing a menu for a stroke patient with dysphagia. What food should be included in the diet?

Mashed potatoes

The nurse is developing a plan of care for a patient with an acute ischemic stroke in the first 48 hours after admission. What activity can the nurse delegate to the unlicensed assistive personnel (UAP)?

Measuring the urine output

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

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

Remove clutter and obstacles

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."

Which action will help a nurse communicate better with a stroke patient with aphasia?

Utilizing touch

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."

What should be included in the nursing plan for prevention of skin breakdown in a stroke patient? Select all that apply.

-Good skin hygiene -Applying emollients to dry skin

The registered nurse is teaching a novice nurse about interventions for a patient with a stroke on the left side of the brain. Which statement by the novice nurse indicates a need for further teaching?

"I should refrain from distracting the patient during a sudden emotional outburst."

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."

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

-Grilled chicken -Vegetable soups

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."

A nurse is explaining the National Institutes of Health Stroke Scale (NIHSS) to a graduate nurse. Which statement best indicates that the graduate nurse understands the purpose of performing the NIHSS?

"The NIHSS evaluates the effects of a stroke."

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."

The nurse finds the wife of a patient who experienced a stroke one week ago crying in the hallway. The wife tells the nurse "I do not know if I can deal with this. He cries about everything and gets so moody with me." What is the best response by the nurse?

"This must be very frustrating for you."

A patient discharged from the hospital after a stroke looks at an old photograph and breaks down, crying inconsolably. What should the nurse tell the patient and the family? Select all that apply.

-"Frustration and depression are common during the first year after stroke." -"Be patient during recovery and do not complain about these involuntary behaviors."

A patient is not able to talk properly after having a stroke but is able to understand what the nurse is saying. While talking to the patient, which sentence stated by the patient will confirm Broca's aphasia? Select all that apply.

-"Ice-cream eat." -"Bird bird two tree."

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? Select all that apply.

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

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

-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.

The nurse is planning self-care priorities with a patient after a stroke. Rank these goals from highest to lowest priority.

-Attain maximum physical functioning -Attain maximum self-care abilities -Maintain stable body functions -Maintain adequate nutrition -Avoid complications of stroke

A nurse is screening patients who are at risk of stroke. Which tests would be appropriate to perform when screening these patients? Select all that apply.

-Blood pressure -Blood sugar level -Serum cholesterol

A patient has sustained a stroke and the nurse is scheduling diagnostic studies to assess the patient's cardiac status. Which diagnostic tests are priorities for the nurse to obtain? Select all that apply.

-Chest x-ray -Cardiac markers -Electrocardiogram

The nurse is preparing a patient with a stroke for diagnostic testing to determine cerebral blood flow. Which tests would be of greatest benefit to obtain this information? Select all that apply.

-Duplex scanning -Digital subtraction angiography -Transcranial Doppler ultrasonography

A nurse is explaining methods to reduce the risk of stroke to a patient. What instructions should the nurse convey to the patient? Select all that apply.

-Eat a diet low in saturated fats -Maintain a normal blood pressure (BP) -Limit consumption of alcohol to moderate levels.

A computed tomography (CT) scan has confirmed embolic stroke in a patient. When explaining the pathophysiology of the stroke to family members, the nurse includes all the following information. Arrange the pathophysiologic process involved in embolic stroke in the correct sequence.

-Emboli originate in the inside layer of the heart -The plaque breaks off from the endocardium -The embolus enters the circulation -The embolus travels upward to the cerebral circulation -The embolus lodges where a vessel narrows or bifurcates -The occlusion causes infarction and edema of the area supplied by the involved vessel

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

-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? Select all that apply.

-Ensure adequate fluid intake -Consider this as a protective response

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

-Good skin hygiene -Applying emollients to dry skin

What rate should blood flow in the brain in order to maintain normal function?

55 mL/100 g

The nurse provides care for a patient who has had a transient ischemic attack (TIA). The patient's spouse asks about the significance of the condition. How should the nurse explain a TIA?

It can be a warning of an impending stroke.

The patient is scheduled for a transcranial Doppler imaging scan. What information will this test provide?

It measures the velocity of blood flow

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

Which medical condition places a patient at a higher risk for an embolic stroke?

Atrial fibrillation

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 who experienced a stroke on the left side of the brain suddenly begins to cry while playing a card game. What is the appropriate action by the nurse?

Distract the patient

A patient with a history of rheumatic heart disease arrives in the emergency room and informs the nurse of sudden loss of strength in the left arm without pain. The patient is unable to lift the arm and says that it "just fell." What condition should the nurse suspect?

Embolic stroke

The nurse assesses atrial fibrillation on the cardiac monitor. What type of stroke does the nurse anticipate for the patient to experience, if left without treatment?

Embolic stroke

The nurse is teaching a patient about the onset of embolic stroke. What information does the nurse include in the teaching plan?

Embolic stroke occurs rapidly.

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 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.

A patient has slurred speech. Which is the correct way for the nurse to perform a quick stoke assessment?

Face drooping, arm weakness, speech difficulties, time

A patient has Broca's aphasia. Which lobe of the brain does the nurse anticipate to have been affected by a stroke?

Frontal lobe

The patient has a sudden onset of symptoms including headache and vomiting. The nurse observes that the patient is also drowsy. Which condition may this patient be experiencing?

Hemorrhagic stroke

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.

A patient has suffered a stroke. Which neurologic factor will the nurse assess and record?

Level of consciousness

A patient who sustained a stroke is having a severe headache, vomiting, dysphagia, dysarthria, and eye movement disturbances. What type of stroke does the nurse determine to correlate with these clinical manifestations?

Intracerebral hemorrhage

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

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 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 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

A patient sustained a stroke and is experiencing cranial nerve deficits. What artery does the nurse suspect to be obstructed?

Vertebral artery

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

While doing a neurologic assessment of a patient who sustained a thrombotic stroke, the nurse records the score of a patient as 40 on a National Institutes of Health Stroke Scale (NIHSS). What does this score indicate?

Severe stroke

The patient is identified as having modifiable risk factors for stroke. Which of these risk factors is will the nurse include in the teaching plan?

Smoking

The nurse assesses a stiff neck and cranial nerve deficits in a patient with head trauma. What does the nurse suspect has occurred with this patient?

Subarachnoid hemorrhage

A nurse is updating the health history of a patient who has been admitted to the hospital with a stroke. What question should the nurse ask the patient's support person?

What was the time of onset of symptoms?

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

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.

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 patient was exhibiting symptoms of a stroke for two hours before the symptoms resolved. Which condition may this patient have experienced?

Transient ischemic attack

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 conducting a physical assessment for a patient in the emergency room. Which finding is consistent with a left-hemispheric stroke?

Unilateral weakness of the right extremities

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

Which intervention is most appropriate when communicating with a patient suffering from aphasia following a stroke?

Use simple, short sentences accompanied by visual cues to enhance comprehension.