Sherpath - Ischemic Stroke

A patient is being treated for an ischemic stroke thought to result in damage to the right brain. The nurse understands that which statements by the patient would support this diagnosis?

"I'm having difficulty telling how far away things are." Spatial-perceptual deficits, such as having difficulty telling how far away things are, are characteristic of right brain damage. "I think this is just an allergic reaction. This paralysis will go away soon." Right brain damage is associated with denial or minimization of the problems such as thinking it is just an allergic reaction. "Ever since these symptoms started, I've had a hard time concentrating on one thing." Right-side brain damage is associated with a short attention span and a difficulty concentrating on one thing.

A patient is being discharged from the hospital after experiencing an ischemic stroke. The nurse is involving the caregivers in the patient teaching. Which statement by the caregiver indicates that further teaching is required?

"If we notice confusion, slurred speech, or facial paralysis, we should immediately administer a low-dose aspirin." Confusion, slurred speech, and facial paralysis are signs of a repeat stroke. The appropriate action is to immediately call 911, not administer aspirin.

A patient who has experienced a stroke asks the nurse what causes the symptoms being experienced. What is the best response by the nurse?

"Neuronal death." When blood flow to the brain is interrupted, neurologic metabolism stops and the cells of the brain die, neuronal death, resulting in the signs and symptoms of a stroke.

The nurse is caring for a patient who experienced an ischemic stroke and is depressed and having trouble coping. What are priority nursing actions for this patient?

Ask the patient how he/she feels about the diagnosis It is important as a nurse to be an active listener and ask how the patient feels about the diagnosis, especially those having trouble coping. Ask the patient if family would like to join to talk about the long-term treatment plan Family should be included in short and long-term goal planning and patient care.

A patient who has suffered an ischemic stroke has been admitted to the hospital and is in stable condition after tPA treatment. Which nursing assessment is a priority for this patient?

Asking the patient simple time and place questions In a stable patient, neurological checks, such as asking the patient simple orientation questions, should be performed.

A patient is diagnosed with acute onset of ischemic stroke and treated with tissue plasminogen activator (tPA). What is the nurse's primary role during tPA administration?

Assess patient level of consciousness During tPA administration the nurse should closely monitor the patient's vital signs and neurologic status, including level of consciousness, to assess for improvement or deterioration related to treatment.

A patient arrives at the emergency department with symptoms of a stroke. Which diagnostic test should the nurse immediately prepare the patient for to further investigate the cause of the patient's symptoms?

Computed tomography (CT) scan A CT scan can rapidly distinguish between ischemic and hemorrhagic stroke. This diagnostic test should be performed within 30 minutes of arriving in emergency department.

A patient has just presented to the emergency room with facial drooping, slurred speech, and left-sided paralysis. The symptoms began 2 hours ago. Which emergent therapy should the nurse prepare the patient for?

Computerized topography (CT) scan A CT Scan should be performed to rule out a hemorrhagic stroke. Once a hemorrhagic stroke has been ruled out, then a medication regimen can be started.

A patient arrives at the emergency department with bradypnea, dysphagia, and difficulty communicating. The patient's caregiver indicates the symptoms came on quickly, just in the last hour. The health care provider suspects the patient is suffering from a stroke. Place the actions the nurse would take in the appropriate order when caring for this patient.

1. Take patient's vital signs and assess airway 2. Prepare patient for CT scan 3. Administer recombinant tissue plasminogen activator (tPA) 4. Administer anticoagulants as needed

A nurse is providing care to a patient following an ischemic stroke. The patient has dysphagia. Which acute care intervention should the nurse include in the patient's care?

Place the patient on aspiration precautions Placing the patient on aspiration precautions is an appropriate intervention to include in the care of a patient with dysphagia.

A patient is being treated for an ischemic stroke and is under observation. The nurse notes that approximately 3 days after the stroke occurred, the patient is nauseous and appears confused and agitated. On assessment, the nurse notes elevated blood pressure and body temperature. What are appropriate nursing actions to prevent further brain injury in this patient?

Sit the patient up Raising the head of the bed or sitting the patient up with pillows to improve venous drainage is an appropriate measure to take to manage increased ICP. Drain the cerebrospinal fluid Cerebrospinal fluid drainage may be used in some patients to reduce intracranial pressure (ICP) if necessary to preserve brain function. Administer acetaminophen (Tylenol) The nurse should administer acetaminophen to address the elevated temperature.

A patient is treated for a transient ischemic attack. The nurse and the health care team will suggest which preventive measures to help prevent an embolic stroke in this patient?

Take aspirin 81 mg/day Daily low-dose aspirin, such as 81 mg/day, is a preventive measure to help reduce the risk of an embolus in a patient treated for TIA. Eat a well-balanced diet Eating a well-balanced diet containing fruits and vegetables and low in salt and sodium is an important lifestyle change that a patient diagnosed with a TIA should adopt to reduce the risk of an ischemic stroke. Limit alcohol consumption Limiting alcohol consumption is an important lifestyle change that a patient diagnosed with a TIA should adopt to reduce the risk of an ischemic stroke. Adopt a moderate exercise regimen Adopting a moderate exercise regimen is an important lifestyle change that a patient diagnosed with a TIA should adopt to reduce the risk of an ischemic stroke.

A patient is being evaluated for discharge. Which is a determining factor in the discharge planning?

The patient's ability to perform activities of daily living (ADLs) The patient's level of independence in ADLs is a critical factor in discharge planning.

A patient is being evaluated for an ischemic stroke. The patient tells the nurse that the primary health care provider indicated that a narrowing of blood vessels caused the stroke. Which type of stroke does the nurse explain that the patient has?

Thrombotic Formation of a thrombus narrows the blood vessels in the brain and is the cause for a thrombotic stroke.

transient ischemic attack

an episode of cerebrovascular insufficiency, usually associated with partial occlusion of a cerebral artery by an atherosclerotic plaque or an embolus. The symptoms vary with the site and degree of occlusion. Disturbance of normal vision in one or both eyes, dizziness, weakness, dysphasia, numbness, or unconsciousness may occur. The attack usually lasts a few minutes. In rare cases symptoms continue for several hours.

A patient arrives at the emergency department and indicates that she has had a stroke. Which assessment findings would the nurse expect to see to support the patient's claim?

Dyspnea A stroke is associated with impairment in respiratory function, which may manifest as dyspnea. Drooling A stroke is associated with impairment in swallowing, which may lead to drooling. Dysphagia A stroke is associated with impairment in mobility and swallowing, which may manifest as dysphagia. Slurred speech A stroke is associated with language disorders involving the expression and comprehension of written or spoken words, which may manifest as slurred speech.

A patient is being treated for an ischemic stroke and asks the nurse if there is any way to prevent complications of a stroke without drug therapy. Which suggestions does the nurse provide?

Eat a lot of fiber A common complication of stroke is constipation. Extra fiber can relieve constipation without drug therapy. Turn every two hours The patient should avoid lying in the same position for a long period of time. Frequent turning can prevent skin breakdown.

The nurse is taking the history of a patient who has suffered a stroke. The patient has a history of atrial fibrillation and reports that the symptoms came "out of nowhere." The nurse suspects the patient suffered which type of stroke?

Embolic Atrial fibrillation is a risk factor for an embolic stroke. Other heart conditions associated with emboli are myocardial infarction and inflammatory and valvular heart conditions.

A patient diagnosed with a transient ischemic attack (TIA) is treated with a carotid endarterectomy (CEA). The patient returns two weeks later having suffered another TIA. Which surgical procedure would the nurse anticipate preparing the patient for?

Extracranial-intracranial (EC-IC) bypass EC-IC bypass is used to reroute blood flow around an obstruction for patients who do not benefit from other forms of therapy.

ischemic stroke

occurs when there is inadequate blood flow (ischemia) to a part of the brain. Functions (i.e., movement, sensation, cognition, and emotion) that were controlled by the affected area of the brain are lost or impaired

A patient is being discharged from the hospital after suffering a stroke that has left the patient immobilized. Which nursing care is a priority to ensure the patient receives appropriate post-hospital care?

Identify appropriate rehabilitation resources At discharge, the nurse should identify community resources for the patient, including appropriate rehabilitation resources for a patient who is immobilized.

A patient is concerned about the risk for ischemic stroke due to a medical history of diabetes and hypertension along with a strong family history of the condition. What advice can the nurse recommend to minimize the risk of stroke?

Maintain blood glucose The risk for stroke is higher in patients with diabetes mellitus. Maintaining blood glucose and preventing or controlling diabetes can minimize risk of stroke. Start an exercise regimen Obesity, diabetes, and hypertension are all risk factors for stroke that can be minimized by starting an exercise regimen to help keep weight under control. Remain on antihypertensive medication Hypertension is the single most important modifiable risk factor of ischemic stroke. Keeping blood pressure under control by remaining on antihypertensive medication will minimize risk of stroke.