Module 7 Neuro Chapter 49

The nurse is assisting the registered nurse (RN) in providing care for a patient who is recovering from a stroke. Which assigned action by the RN should 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 recommendations for being up in a bedside chair.

1. Observe the patient performing active range of motion (ROM) on the affected side. pg. 1012

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 pg. 1009

A child comes to the emergency department with stroke symptoms. What question should the nurse ask the parents first to determine a cause? 1. What is your child's medical history? 2. Does your child do drugs? 3. What medications does your child take? 4. Does your child every fake an illness?

1. What is your child's medical history? pg. 1022

A patient arrives in the emergency department at 0200 exhibiting signs and symptoms of a stroke. The patient went to bed at 2300 and was "feeling fine" but woke up at 0100 to go to the restroom and fell on the way there. The CT scan shows a hemorrhagic stroke. For what reason would tPA therapy be withheld? 1. tPA is not delivered for hemorrhagic stroke. 2. The patient's symptoms have progressed too quickly. 3. The total effects of ischemia are not currently known. 4. Too much time has passed since the symptoms began.

1. tPA is not delivered for hemorrhagic stroke. pg. 1007

A patient began experiencing symptoms of a stroke at 1800 hours. By which time should thrombolytic medications be provided to reverse stroke symptoms? 1. 2230 hours 2. 0100 hours 3. 0230 hours 4. 0600 hours

2. 0100 hours pg. 1007

A patient is admitted from the emergency department to the hospital following the diagnosis of an ischemic stroke. The patient did not qualify for tPA therapy. What findings indicate the patient may have developed a complication? 1. A weakened cough effort 2. A warm, reddened area on the calf 3. High BP 4. Intermittent crying

2. A warm, reddened area on the calf pg. 1009

A patient arrives at the emergency department saying, "Something is wrong. I just don't feel right." Which observation causes the nurse to suspect the patient is experiencing a stroke? 1. Pupils are pinpoint is size. 2. Ataxia is present when the patient attempts to ambulate. 3. The patient is holding their head. 4. The patient is upset and crying.

2. Ataxia is present when the patient attempts to ambulate. pg. 1002

A patient comes to the emergency department with a sudden onset of a severe headache that is "the worst pain of my life." What diagnosis should the nurse assume until proving otherwise? 1. Ischemic stroke 2. Cerebral aneurysm rupture 3. Subarachnoid hemorrhage (SAH) 4. Vasospasm

2. Cerebral aneurysm rupture pg. 1010

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.) 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. pg. 1009

The nurse is preparing to assist a patient with eating who is recovering from a stroke. What action should the nurse take? 1. Have the patient sip liquids in small amounts with a straw. 2. Place the patient in a semi-Fowler 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. pg. 1013

The nurse is providing care for a patient with a cerebral aneurysm and subarachnoid hemorrhage. Which statement by the patient requires additional teaching? 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. pg. 1010

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. On the right side 4. Where the patient designates

3. On the right side pg. 1003

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 BP is 190/110 mm Hg. For which reason will the patient's hypertension remain untreated? 1. The elevated BP will create collateral circulation in the brain. 2. Therapeutic BP 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. pg. 1006

A patient comes into the emergency department with unilateral paralysis, aphasia, and inability to follow directions. Which emergency management should the nurse question? 1. Maintenance of oxygen therapy to a saturation of at least 94% 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 (37.5°C)

3. Scheduling laboratory tests, electrocardiogram (ECG), and computerized tomography (CT) scan to be performed within 45 minutes pg. 1006

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

3. Teach the patient to purposefully check the location of the right limbs. pg. 1009

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 pg. 1010

The nurse is involved in a BP 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.) 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 downward.

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 downward. pg. 1002

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 pg. 1008

The nurse is providing care for a patient who had a stroke, resulting in a language disorder. The nurse asks the patient to stick out their tongue and they raise their arms. How should the nurse document this finding? 1. Dysarthria 2. Expressive aphasia 3. Dysphasia 4. Receptive aphasia

4. Receptive aphasia pg. 1003

A patient comes into the emergency department with symptoms of a stroke that began 2 hours ago. Diagnostic testing confirms an ischemic stroke is present. What medications should the nurse anticipate will be delivered? 1. Heparin 2. Clopidogrel 3. Warfarin 4. Tissue-type plasminogen activator (tPA)

4. Tissue-type plasminogen activator (tPA) pg. 1007