Chapter 57.2

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."

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.

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.

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.

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.

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

"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."

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 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 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."

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 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 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? Select all that apply.

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? Select all that apply.

Assess neurologic status. Assess respiratory status

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

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 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

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? Select all that apply.

Correct hypotension. Correct hypovolemia Continue treatment for stroke.

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.

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 primary health care provider finds neuromuscular and cognitive impairment in a patient with hemorrhagic stroke. Which nursing intervention is most appropriate for the nurse to include in the plan of care?

Encouraging independent exercise

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.

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.

Which are primary methods of preventing a stroke? Select all that apply.

Healthy diet Correct2 Regular exercise Management of blood pressure

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

Impulsive and impatient

A patient has sustained a stroke, and the nurse is preparing to administer fibrinolytic therapy. What is the chronologic order of the events in fibrinolytic therapy?

In fibrinolytic therapy, a recombinant tissue plasminogen activator (tPA) first binds to the fibrin in the thrombi. The fibrinolytic action of tPA converts plasminogen to plasmin. Then, the enzymatic action of plasmin digests fibrin and fibrinogen. This lyses the clot.

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

Mashed potatoes

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 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. Correct2 Monitor the blood sugar level. Correct3 Ensure adequate fluid intake

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

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.

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 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? Select all that apply.

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.

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 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? 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 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

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

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 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? Select all that apply.

Seek spiritual assistance. Correct4 Maintain adequate fluid intake. Correct5 Follow-up for rehabilitation therapy is important

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? Select all that apply.

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

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 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.

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.

Place the following collaborative interventions in order of priority for a patient presenting with acute stroke symptoms.

Using the airway, breathing, circulation (ABC) approach, the first intervention would be to ensure a patent airway. A baseline pulse oximetry reading should then be obtained and supplemental oxygen provided to keep oxygen saturation above 95%. An IV access then will be placed, because this will provide a lifeline for emergency medications as prescribed. Prompt diagnosis of the stroke is imperative, so the patient should be prepared for and transported to radiology for a CT of the brain. Once CT findings are reported, consideration for thrombolytic therapy for nonhemorrhagic strokes will be done next.

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

lopidogrel Correct2 Enoxaparin Correct3 Dipyridamole Correct4 Enteric-coated aspirin