CHAPTER 62 - STROKE

A 63-yr-old patient who began experiencing right arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol? (Put a comma and a space between each answer choice [A, B, C, D].) a. Obtain CT scan without contrast. b. Infuse tissue plasminogen activator (tPA). c. Administer oxygen to keep O2 saturation >95%. d. Use National Institute of Health Stroke Scale to assess patient.

C, D, A, B

After receiving change-of-shift report on the following four patients, which patient should the nurse see first? a. A 60-yr-old patient with right-sided weakness who has an infusion of tPA prescribed b. A 50-yr-old patient who has atrial fibrillation and a new order for warfarin (Coumadin) c. A 30-yr-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine scheduled d. A 40-yr-old patient who had a transient ischemic attack yesterday and has a dose of aspirin due

a. A 60-yr-old patient with right-sided weakness who has an infusion of tPA prescribed

What is an appropriate nursing intervention to promote communication during rehabilitation of the patient with aphasia? a. Allow time for the individual to complete his/her thoughts. b. Use gestures, pictures, and music to stimulate patient responses. c. Structure statements so that the patient does not have to respond verbally. d. Use flashcards with simple words and pictures to promote recall of language.

a. Allow time for the individual to complete his/her thoughts.

A patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will the nurse include in the plan of care? a. Apply intermittent pneumatic compression stockings. b. Assist to dangle on edge of bed and assess for dizziness. c. Encourage patient to cough and deep breathe every 4 hours. d. Insert an oropharyngeal airway to prevent airway obstruction.

a. Apply intermittent pneumatic compression stockings.

A female patient who had a stroke 24 hours ago has expressive aphasia. What is an appropriate nursing intervention to help the patient communicate? a. Ask questions that the patient can answer with "yes" or "no." b. Develop a list of words that the patient can read and practice reciting. c. Have the patient practice her facial and tongue exercises with a mirror. d. Prevent embarrassing the patient by answering for her if she does not respond.

a. Ask questions that the patient can answer with "yes" or "no."

Which statements describe characteristics of a stroke caused by an intracerebral hemorrhage (select all that apply)? a. Carries a poor prognosis b. Caused by rupture of a vessel c. Strong association with hypertension d. Commonly occurs during or after sleep e. Creates a mass that compresses the brain

a. Carries a poor prognosis b. Caused by rupture of a vessel c. Strong association with hypertension e. Creates a mass that compresses the brain

Four days following a stroke, a patient is to start oral fluids and feedings. Before feeding the patient, what should the nurse do first? a. Check the patient's gag reflex. b. Order a soft diet for the patient. c. Raise the head of the bed to a sitting position. d. Assess the patient's ability to swallow tiny amounts of crushed ice.

a. Check the patient's gag reflex.

Which type of stroke is associated with endocardial disorders, has a rapid onset, and is likely to occur during activity? a. Embolic b. Thrombotic c. Intracerebral hemorrhage d. Subarachnoid hemorrhage

a. Embolic

During the secondary assessment of the patient with a stroke, what should be included (select all that apply)? a. Gaze b. Sensation c. Facial palsy d. Proprioception e. Current medications f. Distal motor function

a. Gaze b. Sensation c. Facial palsy d. Proprioception f. Distal motor function

During the acute phase of a stroke, the nurse assesses the patient's vital signs and neurologic status at least every 4 hours. What is a cardiovascular sign that the nurse would see as the body attempts to increase cerebral blood flow? a. Hypertension b. Fluid overload c. Cardiac dysrhythmias d. S3 and S4 heart sounds

a. Hypertension

Indicate whether the following manifestations of a stroke are more likely to occur with right-brain damage (R) or left-brain damage (L). a. _______ Aphasia b. _______ Impaired judgment c. _______ Quick, impulsive behavior d. _______ Inability to remember words e. _______ Left homonymous hemianopsia f. _______ Neglect of the left side of the body g. _______ Hemiplegia of the right side of the body

a. L b. R c. R d. L e. R f. R g. L

A newly admitted patient diagnosed with a right-sided brain stroke has homonymous hemianopsia. Early in the care of the patient, what should the nurse do? a. Place objects on the right side within the patient's field of vision. b. Approach the patient from the left side to encourage the patient to turn the head. c. Place objects on the patient's left side to assess the patient's ability to compensate. d. Patch the affected eye to encourage the patient to turn the head to scan the environment.

a. Place objects on the right side within the patient's field of vision.

Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness. Which patient problem do they determine has the highest priority for the patient? a. Risk for aspiration b. Impaired skin integrity c. Impaired physical mobility d. Disturbed sensory perception

a. Risk for aspiration

A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which response by the nurse is accurate? a. "The diseased portion of the artery is replaced with a synthetic graft." b. "The obstructing plaque is surgically removed from inside an artery in the neck." c. "A wire is threaded through an artery in the leg to the clots in the carotid artery, and clots are removed." d. "A catheter with a deflated balloon is positioned at the narrow area, and the balloon flattens the plaque."

b. "The obstructing plaque is surgically removed from inside an artery in the neck."

A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours. What topic should the nurse anticipate teaching the patient? a. tPA b. Aspirin c. Warfarin d. Nimodipine

b. Aspirin

Several weeks after a stroke, a 50-yr-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention should be planned to begin an effective bladder training program? a. Limit fluid intake to 1200 mL daily to reduce urine volume. b. Assist the patient onto the bedside commode every 2 hours. c. Perform intermittent catheterization after each voiding to check for residual urine. d. Use an external "condom" catheter to protect the skin and prevent embarrassment.

b. Assist the patient onto the bedside commode every 2 hours.

What will the nurse tell the patient who has cerebral atherosclerosis about taking clopidogrel (Plavix)? a. Monitor and record the blood pressure daily. b. Call the health care provider if stools are tarry. c. Clopidogrel will dissolve clots in the cerebral arteries. d. Clopidogrel will reduce cerebral artery plaque formation.

b. Call the health care provider if stools are tarry.

A 70-yr-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? a. Take the patient's blood pressure. b. Check the respiratory rate and effort. c. Assess the Glasgow Coma Scale score. d. Send the patient for a computed tomography (CT) scan.

b. Check the respiratory rate and effort.

A diagnosis of a ruptured cerebral aneurysm has been made in a patient with manifestations of a stroke. The nurse anticipates which treatment option that would be considered for the patient? a. Hyperventilation therapy b. Surgical clipping of the aneurysm c. Administration of hyperosmotic agents d. Administration of thrombolytic therapy

b. Surgical clipping of the aneurysm

The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse? a. The pulse rate is 102 beats/min. b. The patient has difficulty speaking. c. The blood pressure is 144/86 mm Hg. d. There are fine crackles at the lung bases.

b. The patient has difficulty speaking.

Which information about the patient who had a subarachnoid hemorrhage is most important to communicate to the health care provider? a. The patient reports having a stiff neck. b. The patient's blood pressure (BP) is 90/50 mm Hg. c. The patient reports a severe and unrelenting headache. d. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).

b. The patient's blood pressure (BP) is 90/50 mm Hg.

Which intervention can the nurse delegate to the licensed practical nurse (LPN) when caring for a patient following an acute stroke? a. Assess the patient's neurologic status. b. Assess the patient's gag reflex before beginning feeding. c. Administer ordered antihypertensives and platelet inhibitors. d. Teach the patient's caregivers strategies to minimize unilateral neglect.

c. Administer ordered antihypertensives and platelet inhibitors.

The nurse is caring for a patient who has been experiencing stroke symptoms for 60 minutes. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/VN)? a. Assess the patient's gag and cough reflexes. b. Determine when the stroke symptoms began. c. Administer the prescribed short-acting insulin. d. Infuse the prescribed IV metoprolol (Lopressor).

c. Administer the prescribed short-acting insulin.

A patient will attempt oral feedings for the first time after having a stroke. After assessing the gag reflex, what action should the nurse take? a. Order a varied pureed diet. b. Assess the patient's appetite. c. Assist the patient into a chair. d. Offer the patient a sip of juice.

c. Assist the patient into a chair.

A left-handed patient with left-sided hemiplegia has difficulty feeding himself. Which intervention should the nurse include in the plan of care? a. Provide a wide variety of food choices. b. Provide oral care before and after meals. c. Assist the patient to eat with the right hand. d. Teach the patient the "chin-tuck" technique.

c. Assist the patient to eat with the right hand.

A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first? a. Complete blood count (CBC) b. Chest radiograph (chest x-ray) c. Computed tomography (CT) scan d. 12-Lead electrocardiogram (ECG)

c. Computed tomography (CT) scan

What concern should the nurse anticipate for a patient who had a right hemisphere stroke? a. Right-sided hemiplegia b. Speech-language deficits c. Denial of deficits and impulsiveness d. Depression and distress about disability

c. Denial of deficits and impulsiveness

A patient with a stroke has a right-sided hemiplegia. What does the nurse teach the family to prepare them to cope with the behavior changes seen with this type of stroke? a. Ignore undesirable behaviors manifested by the patient. b. Provide directions to the patient verbally in small steps. c. Distract the patient from inappropriate emotional responses. d. Supervise all activities before allowing the patient to do them independently.

c. Distract the patient from inappropriate emotional responses.

A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the patient says, "I don't need the aspirin today. I don't have a fever." Which action should the nurse take? a. Document that the patient refused the aspirin. b. Tell the patient that the aspirin is used to prevent a fever. c. Explain that the aspirin is ordered to decrease stroke risk. d. Call the health care provider to clarify the medication order.

c. Explain that the aspirin is ordered to decrease stroke risk.

A patient is admitted to the hospital with a left hemiplegia. To determine the size and location and to ascertain whether a stroke is ischemic or hemorrhagic, what will the nurse anticipate that the health care provider (HCP) will request? a. Lumbar puncture b. Cerebral angiography c. MRI d. CT scan with contrast

c. MRI

What topic should the nurse anticipate teaching a patient who had a brief episode of tinnitus, diplopia, and dysarthria with no residual effects? a. Cerebral aneurysm clipping b. Heparin intravenous infusion c. Oral low-dose aspirin therapy d. Tissue plasminogen activator (tPA)

c. Oral low-dose aspirin therapy

In promoting health maintenance for prevention of strokes, the nurse understands that the highest risk for the most common type of stroke is present in which people? a. Blacks b. Women who smoke c. Persons with hypertension and diabetes d. Those who are obese with high dietary fat intake

c. Persons with hypertension and diabetes

The rehabilitation nurse assesses the patient, caregiver, and family before planning the rehabilitation program for this patient. What must be included in this assessment (select all that apply)? a. Cognitive status of the family b. Patient resources and support c. Physical status of all body systems d. Rehabilitation potential of the patient e. Body strength remaining after the stroke f. Patient and caregiver expectations of the rehabilitation

c. Physical status of all body systems d. Rehabilitation potential of the patient f. Patient and caregiver expectations of the rehabilitation

Which intervention should the nurse include in the plan of care for a patient with new right-sided homonymous hemianopsia after a stroke?? a. Apply an eye patch to the right eye. b. Approach the patient from the right side. c. Place needed objects on the patient's left side. d. Teach the patient that the left visual deficit will resolve.

c. Place needed objects on the patient's left side.

The patient has a lack of comprehension of both verbal and written language. Which type of communication difficulty does this patient have? a. Dysarthria b. Fluent dysphasia c. Receptive aphasia d. Expressive aphasia

c. Receptive aphasia

What is an appropriate food for a patient with a stroke who has mild dysphagia? a. Fruit juices b. Pureed meat c. Scrambled eggs d. Fortified milkshakes

c. Scrambled eggs

A patient admitted with possible stroke has been aphasic for 3 hours and has a current blood pressure (BP) of 174/94 mm Hg. Which order by the health care provider should the nurse question? a. Keep head of bed elevated at least 30 degrees. b. Infuse normal saline intravenously at 75 mL/hr. c. Start a labetalol drip to keep BP less than 140/90 mm Hg. d. Begin tissue plasminogen activator (tPA) intravenously per protocol.

c. Start a labetalol drip to keep BP less than 140/90 mm Hg.

A patient with a right hemisphere stroke has unilateral neglect. During the patient's rehabilitation, what nursing intervention is important for the nurse to do? a. Avoid positioning the patient on the affected side. b. Place all objects for care on the patient's unaffected side. c. Teach the patient to care consciously for the affected side. d. Protect the affected side from injury with pillows and supports.

c. Teach the patient to care consciously for the affected side.

What primarily determines the neurologic functions that are affected by a stroke? a. The amount of tissue area involved b. The rapidity of the onset of symptoms c. The brain area perfused by the affected artery d. The presence or absence of collateral circulation

c. The brain area perfused by the affected artery

A patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving a prescribed dose of aspirin? a. The patient has dysphasia. b. The patient has atrial fibrillation. c. The patient reports that symptoms began with a severe headache. d. The patient has a history of brief episodes of right-sided hemiplegia.

c. The patient reports that symptoms began with a severe headache.

Which stroke risk factor for a 48-yr-old male patient in the clinic is most important for the nurse to address? a. The patient is 25 pounds above the ideal weight. b. The patient drinks a glass of red wine with dinner daily. c. The patient's usual blood pressure (BP) is 170/94 mm Hg. d. The patient works at a desk and relaxes by watching television.

c. The patient's usual blood pressure (BP) is 170/94 mm Hg.

During change of shift report, a nurse is told that a patient has an occluded left posterior cerebral artery. What finding should the nurse anticipate? a. Dysphasia b. Confusion c. Visual deficits d. Poor judgment

c. Visual deficits

A thrombus that develops in a cerebral artery does not always cause a loss of neurologic function because a. the body can dissolve atherosclerotic plaques as they form. b. some tissues of the brain do not require constant blood supply to prevent damage. c. circulation via the Circle of Willis may provide blood supply to the affected area of the brain. d. neurologic deficits occur only when major arteries are occluded by thrombus formation around atherosclerotic plaque.

c. circulation via the Circle of Willis may provide blood supply to the affected area of the brain.

A patient's wife asks the nurse why her husband did not receive the clot-busting medication (tissue plasminogen activator [tPA]) she has been reading about. Her husband is diagnosed with a hemorrhagic stroke. What is the best response by the nurse to the patient's wife? a. "He didn't arrive within the time frame for that therapy." b. "Not everyone is eligible for this drug. Has he had surgery lately?" c. "You should discuss the treatment of your husband with his doctor." d. "The medication you are talking about dissolves clots and could cause more bleeding in your husband's brain."

d. "The medication you are talking about dissolves clots and could cause more bleeding in your husband's brain."

The incidence of ischemic stroke in patients with TIAs and other risk factors is reduced with the administration of which medication? a. Nimodipine b. Furosemide (Lasix) c. Warfarin (Coumadin) d. Daily low-dose aspirin

d. Daily low-dose aspirin

A patient being admitted with a stroke has right-sided facial drooping and right-sided arm and leg paralysis. Which finding should the nurse expect? a. Impulsive behavior b. Right-sided neglect c. Hyperactive left-sided tendon reflexes d. Difficulty comprehending instructions

d. Difficulty comprehending instructions

What is a nursing intervention that is indicated for the patient with hemiplegia? a. The use of a footboard to prevent plantar flexion b. Immobilization of the affected arm against the chest with a sling c. Positioning the patient in bed with each joint lower than the joint proximal to it d. Having the patient perform passive range of motion (ROM) of the affected limb with the unaffected limb

d. Having the patient perform passive range of motion (ROM) of the affected limb with the unaffected limb

The nurse can best assist the patient and family in coping with the long-term effects of a stroke by doing what? a. Informing family members that the patient will need assistance with almost all activities of daily living (ADLs) b. Explaining that the patient's prestroke behavior will return as improvement progresses c. Encouraging the patient and family members to seek assistance from family therapy or stroke support groups d. Helping the patient and family understand the significance of residual stroke damage to promote problem solving and planning

d. Helping the patient and family understand the significance of residual stroke damage to promote problem solving and planning

A carotid endarterectomy is being considered as treatment for a patient who has had several TIAs. What should the nurse explain to the patient about this surgery? a. It involves intracranial surgery to join a superficial extracranial artery to an intracranial artery. b. It is used to restore blood circulation to the brain following an obstruction of a cerebral artery. c. It is used to open a stenosis in a carotid artery with a balloon and stent to restore cerebral circulation. d. It involves removing an atherosclerotic plaque in the carotid artery to prevent an impending stroke.

d. It involves removing an atherosclerotic plaque in the carotid artery to prevent an impending stroke.

What is the priority intervention in the ED for the patient with a stroke? a. IV fluid replacement b. Giving osmotic diuretics to reduce cerebral edema c. Starting hypothermia to decrease the oxygen needs of the brain d. Maintaining respiratory function with a patent airway and oxygen administration

d. Maintaining respiratory function with a patent airway and oxygen administration

A patient with a left-brain stroke suddenly bursts into tears when family members visit. How should the nurse respond? a. Use a calm voice to ask the patient to stop the crying behavior. b. Explain to the family that depression is normal following a stroke. c. Have the family members leave the patient alone for a few minutes. d. Teach the family that emotional outbursts are common after strokes.

d. Teach the family that emotional outbursts are common after strokes.

A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? a. The patient's speech is difficult to understand. b. The patient's blood pressure (BP) is 144/90 mm Hg. c. The patient takes a diuretic because of a history of hypertension. d. The patient has atrial fibrillation and takes warfarin (Coumadin).

d. The patient has atrial fibrillation and takes warfarin (Coumadin).

A patient comes to the emergency department (ED) with numbness of the face and an inability to speak. While the patient awaits examination, the symptoms disappear and the patient requests discharge. Why should the nurse emphasize that it is important for the patient to be treated before leaving? a. The patient has probably experienced an asymptomatic lacunar stroke. b. The symptoms are likely to return and progress to worsening neurologic deficit in the next 24 hours. c. Neurologic deficits that are transient occur most often as a result of small hemorrhages that clot off. d. The patient has probably had a transient ischemic attack (TIA), which is a sign of progressive cerebrovascular disease.

d. The patient has probably had a transient ischemic attack (TIA), which is a sign of progressive cerebrovascular disease.

A patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. Health records show a history of several transient ischemic attacks (TIAs). What should the nurse anticipate for this patient? a. Surgical endarterectomy b. Transluminal angioplasty c. Intravenous heparin drip administration d. Tissue plasminogen activator (tPa) infusion

d. Tissue plasminogen activator (tPa) infusion