Chapter 67
If warfarin is contraindicated as a treatment for stroke, which medication is the best option? Dipyridamole Aspirin Clopidogrel Ticlodipine
Correct response: Aspirin Explanation: If warfarin is contraindicated, aspirin is the best option, although other medications may be used if both are contraindicated.
How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tPA)? Every 15 minutes Every 30 minutes Every 45 minutes Every hour
Correct response: Every 15 minutes Explanation: Neurological assessment and vital signs (except temperature) should be taken every 15 minutes initially while the patient is receiving tPA infusion.
Hemorrhagic
Slower, usually plateaus at about 18 months
Ischemic
Usually plateaus at 6 months
The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regimen, to maintain a healthy weight, and to adopt a reasonable exercise program. This advice is based on research data that shows the most important risk factor for stroke is: Obesity Dyslipidemia Smoking Hypertension
Correct response: Hypertension Explanation: Hypertension is the most modifiable risk factor for either ischemic or hemorrhagic stroke. Unfortunately, it remains under-recognized and undertreated in most communities.
The nurse is caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke does the nurse know this client has? Ischemic Hemorrhagic Right-sided Left-sided
Correct response: Ischemic Explanation: Ischemic strokes occur when a thrombus or embolus obstructs an artery carrying blood to the brain; about 80% of strokes are the ischemic variety. The other options are incorrect.
The provider diagnoses the patient as having had an ischemic stroke. The etiology of an ischemic stroke would include which of the following? Cardiogenic emboli Cerebral aneurysm Arteriovenous malformation Intracerebral hemorrhage
Correct response: Cardiogenic emboli Explanation: Aneurysms, hemorrhages, and malformations are all examples of a hemorrhagic stroke. An embolism can block blood flow, leading to ischemia.
A community health nurse is conducting a workshop for unlicensed care providers who work in a chain of long-term care facilities. The nurse is teaching the participants about the signs and symptoms of stroke. What signs and symptoms should the nurse identify? Select all that apply. Epistaxis (nosebleed) Confusion Sudden numbness Sudden ear pain Visual disturbances
Correct response: Confusion Sudden numbness Visual disturbances Explanation: The most common symptoms of stroke include numbness or weakness of the face, arm, or leg, especially on one side of the body; confusion or change in mental status; trouble speaking or understanding speech; visual disturbances; difficulty walking, dizziness, or loss of balance or coordination; and sudden, severe headache.
A client who is at high-risk for a cerebrovascular accident has medication ordered to lower their cholesterol and to prophylactically anticoagulate them. What specific agent might be diagnosed for this client? Daily aspirin Heparin Victorin Celebrex
Correct response: Daily aspirin Explanation: To manage atherosclerosis and the consequences of cardiac dysrhythmias, especially atrial fibrillation, cholesterol-lowering drugs and prophylactic anticoagulant or antiplatelet therapy are prescribed. Specific agents include daily aspirin as well as antiplatelet or anticoagulant therapy such as clopidogrel (Plavix), ticlopidine (Ticlid), warfarin (Coumadin), and dipyridamole (Persantine). Heparin is not the drug of choice for prophylactic anticoagulation therapy. Victorin is a distractor for this question. Celebrex is not a drug to lower cholesterol or anticoagulate.
A client undergoes cerebral angiography for evaluation of a subarachnoid hemorrhage. Which findings indicate spasm or occlusion of a cerebral vessel by a clot? Nausea, vomiting, and profuse sweating Hemiplegia, seizures, and decreased level of consciousness Difficulty breathing or swallowing Tachycardia, tachypnea, and hypotension
Correct response: Hemiplegia, seizures, and decreased level of consciousness Explanation: Spasm or occlusion of a cerebral vessel by a clot causes signs and symptoms similar to those of a stroke: hemiplegia, seizures, decreased level of consciousness, aphasia, hemiparesis, and increased focal symptoms. Nausea, vomiting, and profuse sweating suggest a delayed reaction to the contrast medium used in cerebral angiography. Difficulty breathing or swallowing may signal a hematoma in the neck. Tachycardia, tachypnea, and hypotension suggest internal hemorrhage.
Which is a contraindication for the administration of tissue plasminogen activator (t-PA)? Intracranial hemorrhage Ischemic stroke Age 18 years or older Systolic blood pressure less than or equal to 185 mm Hg
Correct response: Intracranial hemorrhage Explanation: Intracranial hemorrhage, neoplasm, and aneurysm are contraindications for t-PA. Clinical diagnosis of ischemic stroke, age 18 years or older, and a systolic blood pressure less than or equal to 185 mm Hg are eligibility criteria.
A client has experienced an ischemic stroke that has damaged the lower motor neurons of the brain. Which of the following deficits would the nurse expect during assessment? Limited attention span and forgetfulness Visual agnosia Lack of deep tendon reflexes Auditory agnosia
Correct response: Lack of deep tendon reflexes Explanation: Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia. If damage has occurred to the frontal lobe, learning capacity, memory, or other higher cortical intellectual functions may be impaired. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and lack of motivation. Damage to the lower motor neurons may cause decreased muscle tone, flaccid muscle paralysis, and a decrease in or loss of reflexes.
A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings? Transient ischemic attack (TIA) Left-sided cerebrovascular accident (CVA) Right-sided cerebrovascular accident (CVA) Completed Stroke
Correct response: Left-sided cerebrovascular accident (CVA) Explanation: When the infarct is on the left side of the brain, the symptoms are likely to be on the right, and the speech is more likely to be involved. If the MRI reveals an infarct, TIA is no longer the diagnosis. There is not enough information to determine if the stroke is still evolving or is complete.
A client has experienced an ischemic stroke that has damaged the frontal lobe of his brain. Which of the following deficits does the nurse expect to observe during assessment? Limited attention span and forgetfulness Hemiplegia or hemiparesis Lack of deep tendon reflexes Visual and auditory agnosia
Correct response: Limited attention span and forgetfulness Explanation: Damage to the frontal lobe may impair learning capacity, memory, or other higher cortical intellectual functions. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and a lack of motivation. Damage to the motor neurons may cause hemiparesis, hemiplegia, and a change in reflexes. Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia.
Which of the following is accurate regarding a hemorrhagic stroke? Main presenting symptom is an "exploding headache." Functional recovery usually plateaus at 6 months. One of the main presenting symptoms is numbness or weakness of the face. It is caused by a large-artery thrombosis.
Correct response: Main presenting symptom is an "exploding headache." Explanation: One of hemorrhagic stroke's main presenting symptom is an "exploding headache." In ischemic stroke, functional recovery usually plateaus at 6 months; it may be caused by a large artery thrombosis and may have a presenting symptoms of numbness or weakness of the face.
The nurse is caring for a client diagnosed with a hemorrhagic stroke. The nurse recognizes that which intervention is most important? Elevating the head of the bed to 30 degrees Monitoring for seizure activity Administering a stool softener Maintaining a patent airway
Correct response: Maintaining a patent airway Explanation: Maintaining the airway is the most important nursing intervention. Immediate complications of a hemorrhagic stroke include cerebral hypoxia, decreased cerebral blood flow, and extension of the area of injury. Providing adequate oxygenation of blood to the brain minimizes cerebral hypoxia. Brain function depends on delivery of oxygen to the tissues. Administering supplemental oxygen and maintaining hemoglobin and hematocrit at acceptable levels will assist in maintaining tissue oxygenation. All other interventions are appropriate, but the airway takes priority. The head of the bed should be elevated to 30 degrees, monitoring the client because of the risk for seizures, and stool softeners are recommended to prevent constipation and straining, but these are not the most important interventions.
A transcranial Doppler ultrasonography detects cerebral vasospasms in a client experiencing lethargy 8 days following a subarachnoid hemorrhage. The nurse anticipates which therapeutic intervention? Fluid restriction Nitroprusside IV Nimodipine PO Phenytoin IV
Correct response: Nimodipine PO Explanation: Medication may be effective in the treatment of vasospasm. Based on one theory, that vasospasm is caused by an increased influx of calcium into the cell, medication therapy may be used to block or antagonize this action and prevent or reverse the action of vasospasm if already present. The most frequently used calcium channel blocker is nimodipine. The other interventions and medications are not used to treat vasospasms.
A patient is brought to the emergency department with a possible stroke. What initial diagnostic test for a stroke, usually performed in the emergency department, would the nurse prepare the patient for? 12-lead electrocardiogram Carotid ultrasound study Noncontrast computed tomogram Transcranial Doppler flow study
Correct response: Noncontrast computed tomogram Explanation: The initial diagnostic test for a stroke is usually a noncontrast computed tomography (CT) scan. This should be performed within 25 minutes or less from the time the patient presents to the emergency department (ED) to determine if the event is ischemic or hemorrhagic (the category of stroke determines treatment).
While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are: Weakness on one side of the body and difficulty with speech Severe headache and early change in level of consciousness Foot drop and external hip rotation Confusion or change in mental status
Correct response: Severe headache and early change in level of consciousness Explanation: The main presenting symptoms for ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body, confusion or change in mental status, and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Foot drop and external hip rotation can occur if a stroke victim is not turned or positioned correctly.
A client is hospitalized when presenting to the emergency department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to his presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what? Left-sided stroke Right-sided stroke Cerebral aneurysm Transient ischemic attack
Correct response: Transient ischemic attack Explanation: A transient ischemic attack (TIA) is a sudden, brief attack of neurologic impairment caused by a temporary interruption in cerebral blood flow. Symptoms may disappear within 1 hour; some continue for as long as 1 day. When the symptoms terminate, the client resumes his or her presymptomatic state. The symptoms do not describe a left- or right-sided stroke or a cerebral aneurysm.
The nurse is providing information about strokes to a community group. Which of the following would the nurse identify as the primary initial symptoms of an ischemic stroke? Weakness on one side of the body and difficulty with speech Severe headache and early change in level of consciousness Foot drop and external hip rotation Vomiting and seizures
Correct response: Weakness on one side of the body and difficulty with speech Explanation: The main presenting symptoms for an ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body; confusion or change in mental status; and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Foot drop and external hip rotation are things that can occur if a stroke victim is not turned or positioned correctly.
A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the health care provider in the emergency department. Which is the origin of the client's symptoms? impaired cerebral circulation cardiac disease diabetes insipidus hypertension
Correct response: impaired cerebral circulation Explanation: TIAs involve the same mechanism as in the ischemic cascade, but symptoms are transient (< 24 hours) and there is no evidence of cerebral tissue infarction. The ischemic cascade begins when cerebral blood flow decreases to less than 25 mL/100 g/min and neurons are no longer able to maintain aerobic respiration. Thus, a TIA results directly from impaired blood circulation in the brain. Atherosclerosis, cardiac disease, hypertension, or diabetes can be risk factors for a TIA but do not cause it.