N3 CVA Quiz 3

For the stroke scale, what is considered normal and at which number should an endovascular repair be performed?

0 - 6 is NORMAL 6 or greater should do endo repair

What is important to remember with the neck and hip after stroke?

Avoid neck and hip flexion because it increases intrathoracic pressure Hip flexion in a patient with elevated ICP should be avoided at all times. [1] Flexion of the hips puts pressure on the abdominal cavity, which leads to increased intrathoracic pressure

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? Large artery thrombosis Cerebral aneurysm Cardiogenic emboli Small artery thrombosis

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

Posterior brain circulation comes from:

2 vertebral arteries - subclavian arteries

Frontal Lobe

A region of the cerebral cortex that has specialized areas for CONCENTRATION, movement, abstract thinking, planning, memory, and judgement

BE FAST stands for:

Balance - loss of balance? Headache, dizziness. Eyes - sudden loss of vision in one or both eyes Face - any unevenness? Arms - weakness Speech - difficulty speaking Time - if any are yes, call 911... time = brain

Anterior brain circulation comes from

CAROTID artery, branching off to internal carotid artery

CAMM for FRONTAL LOBE stands for?

Concentration Abstract thinking Motor Function Memory

What medications would make t-PA contraindicated?

Heparin or Warfarin... INR has to be equal or less than 1.7. Platelets must be greater than 100,0000

Right sided stroke

Left visual field deficit, paralyzed left side, spatial/perceptual deficits, distractibility, behavioral style becomes quick/impulsive, performance memory deficits. Lacks deficit awareness.

Left sided stroke

Right visual field deficit. paralyzed right side, speech/language deficits, altered intellectual ability, behavior style becomes slow and cautious.

Which drug do patients who leave the hospital after a stroke need to be prescribed, otherwise a reason must be given for why?

STATIN

How soon must a person be given an IV bolus of t-PA after arrival to the ED?

WITHIN 45 minutes

dysarthria.

difficulty forming words during communication

dysphasia is... dysphagia....

dysphaSia is difficulty Speaking dysphaGia is difficulty swallowing (Gulp)

What are the three types of aphasia

expressive, receptive, global

Agnosia

failure to recognize familiar objects perceived by the senses

hemiparesis

weakness on one side of the body

flacid paralysis

weakness or loss of muscle due to injury or disease of the motor neurons

A client is admitted for evaluation of cerebral aneurysm. Which assessment finding is of greatest importance in prioritizing nursing care to this client? Report of headache off and on for past month No bowel movement since yesterday Nausea Frequent voiding

Explanation: Nausea needs to be controlled to prevent vomiting, which can greatly increase the intracranial pressure and subsequently rupture the aneurysm. Report of headache for past month is significant to the evaluation at hand but should be addressed after the nausea has been controlled. Having no bowel movement since yesterday is not significant; although, every effort should be made to prevent constipation. Frequent voiding is expected especially with the use of osmotic diuretics.

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 Two hour time period of the stroke Taking digoxin Surgery 6 weeks ago

International normalized ratio greater than 2 Explanation: The client is at risk for further bleeding if the international normalized ratio is greater than 2.

Parietal Lobe

L and R orientation, analyzes sensory function, and shape discrimination.

Why do they need to do a NON-CONTRAST CT scan for a stroke patient?

Strokes don't show up until 24 hours later... so that means treatment can be done.

When can you give t-PA?

Within 3 - 4.5 hours. To give after 3 hours, you must get consent , patient needs to know that their risk of bleeding will increase.

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 best alternative medication to give is dipyridamole. aspirin. clopidogrel. ticlopidine.

aspirin. Explanation: If warfarin is contraindicated, aspirin is the best option, although other medications may be used if both are contraindicated.

Temporal lobe is by your _____ and it's responsible for _______

by your ears, contains auditory receptive areas. Plays a role in memory of sound, language, and music

apraxia

impaired ability to carry out motor activities despite intact motor function

ataxia

inability to perform coordinated movements

agnosia

inability to recognize objects

aphasia

inability to speak OR understand language

What is homonymous hemianopsia?

loss of half of the field of view on the same side in both eyes

is tPA used for hemorrhagic

no

hemiplagia

paralysis of one side of the body

Neurovasvular and Vital Sign checks how often after endovascular therapy? How often during tPA? How often for vascular checks?

q 15 minutes for the first 2 hours (SAME AS tPA then q 30 minutes for the next 6 hours then HOURLY for 16 hours *Vascular checks are done every 6 hours.

dysarthria

slurred speech

Occipital sounds like _____ and is responsible for ______

sounds like ocular responsible for visual interpretation/visual memory

spastic paralysis

stiff and awkward muscle control caused by a central nervous system disorder

carotid endarterectomy

the surgical removal of the lining of a portion of a clogged carotid artery leading to the brain

A client has a 12-year history of migraine headaches and is frustrated over how these headaches impact lifestyle. The nurse discusses the potential triggers of the client's migraines. Which is not a potential trigger to migraines? seasonal changes reproductive hormone fluctuations specific food chemicals medications

seasonal changes Explanation: Researchers believe the contributing cofactors for the cause of migraines are from changes in serotonin receptors that promote dilation of cerebral blood vessels and pain intensification from neurochemicals released from the trigeminal nerve. It has been suggested that fluctuations in reproductive hormones, chemicals in certain foods, and medications can trigger migraines.

A patient having an acute stroke with no other significant medical disorders has a blood glucose level of 420 mg/dL. What significance does the hyperglycemia have for this patient? The patient has new onset diabetes. This is significant for poor neurologic outcomes. The patient has developed diabetes insipidus due to the location of the stroke. The patient has liver failure.

This is significant for poor neurologic outcomes. Explanation: Hyperglycemia has been associated with poor neurologic outcomes in acute stroke and should be treated if the blood glucose is above 140 mg/dL (Summers et al., 2009).

What does the swallow test entail?

tsp water -> 30 mL water -> 60 mL water -> pass -> diet

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 Aspiration Risk Impaired Swallowing 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.

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

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.

Impaired mobility r/t hemiplagia... How often do they need to be repositioned? How often for passive/active ROM? How often for prone position and why?

Reposition q 2 hours ROM: 4 - 5 hours daily Prone 15 - 30 minutes to help gait, hip joints, draining secretions