EAQ 57 Stroke and Stroke Management (2EAQ)
A patient is not able to talk properly after having a stroke but is able to understand what the nurse is saying. While talking to the patient, which sentence stated by the patient will confirm Broca's aphasia? Select all that apply. A· "Ice cream eat." B· "My dog is thirsty." C· "Bird bird two tree." D· "You are very caring." E· "I like to go to the park."
A, C
Which nursing interventions would be included in the plan of care to prevent skin breakdown in a patient who had a stroke? SATA A· Using pillows under lower extremities B· Massaging the damaged area C· Applying emollients to dry skin D· Minimizing the frequency of position changes E· Administering back rubs with alcohol for a cooling effect
. Using pillows under lower extremities C. Applying emollients to dry skin Rationale: The skin of a patient with stroke is particularly susceptible to breakdown related to loss of sensation, decreased circulation, and immobility. Therefore the nursing prevention plan for skin breakdown should include pressure relief interventions, such as using pillows under the lower extremities to reduce pressure on the heels, position changes, application of emollients to dry skin, good skin hygiene, and early mobility. Massage to the damaged area may cause additional damage and should be avoided. Back rubs can be very relaxing but should be done with lotion or oil, not alcohol, which is very drying to the skin.
While assessing the level of consciousness in a patient with a stroke, the nurse asks the patient the month and the patient's age. The patient knew his or her age but could not state what month it was. Which score would the nurse give to the patient using the National Institutes of Health Stroke Scale (NIHSS)? Record your answer using a whole number. · ANS:
1
Which tests would be of greatest benefit to obtain information about cerebral blood flow in a patient who had a stroke? Select all that apply. A· Duplex scanning B· Electroencephalogram (EEG) C· Digital subtraction angiography D· Transcranial Doppler ultrasonography E· MRI
A, C, D
Arrange the pathophysiologic process involved in embolic stroke in the correct sequence. 1. Emboli originate in the inside layer of the heart. 2. The plaque breaks off from the endocardium. 3. The embolus enters the circulation. 4. The embolus travels upward to the cerebral circulation. 5. The embolus lodges where a vessel narrows or bifurcates. 6. The occlusion causes infarction and edema of the area supplied by the involved vessel.
1. Emboli originate in the inside layer of the heart. 2. The plaque breaks off from the endocardium. 3. The embolus enters the circulation. 4. The embolus travels upward to the cerebral circulation. 5. The embolus lodges where a vessel narrows or bifurcates. 6. The occlusion causes infarction and edema of the area supplied by the involved vessel.
Place the following collaborative interventions in order of priority for a patient presenting with acute stroke symptoms. 1. Ensure patent airway. 2. Perform pulse oximetry. 3. Provide supplemental oxygen as indicated. 4. Establish IV access. 5. Obtain CT scan. 6. Anticipate thrombolytic therapy.
1. Ensure patent airway. 2. Perform pulse oximetry. 3. Provide supplemental oxygen as indicated. 4. Establish IV access. 5. Obtain CT scan. 6. Anticipate thrombolytic therapy.
Place the responses from the motor response section of the Glasgow Coma Scale (GCS) in order from best response to worst response. 1. Obeys simple commands 2. Localizing pain 3. Withdrawal from pain 4. Flexion to pain 5. Extension to pain 6. Limbs remain flaccid
1. Obeys simple commands 2. Localizing pain 3. Withdrawal from pain 4. Flexion to pain 5. Extension to pain 6. Limbs remain flaccid
A patient has been admitted to the hospital with acute cerebral infarction. The patient is completely paralyzed on the left side of the face and does not recognize the hand. Other neurologic functions are normal. According to the National Institutes of Health Stroke Scale (NIHSS), which score would this patient be given? Record the answer using a whole number. · ANS:
5
The nurse will prioritize management of which problem in a patient recovering from a stroke? A· Dysphagia (aspiration could be fatal) B· Vision problems C· Impaired communication D· Impaired physical mobility
A
Which action would the nurse take first for a patient arriving at the emergency department with headache, nausea, hypertension, and difficulty talking? A· Prepare the patient for a CT scan. B· Place antiembolism stockings on the patient. C· Place a stat consult for the speech-language pathologist (SLP). D· Prepare to administer recombinant tissue plasminogen activator (tPA).
A
Which artery has a defect that is related to the cause of aphasia in a patient with a stroke? A· Vertebral artery B· Middle cerebral artery (nerve deficits or coma) C· Anterior cerebral artery (motor or sensory deficits) D· Posterior cerebral artery (visual hallucinations or motor deficits)
A
Which artery would be obstructed if a patient sustained a stroke and is experiencing cranial nerve deficits? A· Vertebral artery B· Middle cerebral artery C· Anterior cerebral artery D· Posterior cerebral artery
A
Which clinical manifestation is associated with a stroke on the right side of the brain? A· Impulsiveness B· Impaired speech (left side) C· Slow performance (left side) D· Paralyzed right side (left side)
A
Which information will a transcranial Doppler (TCD) ultrasonography provide? A· It measures the velocity of blood flow. B· It identifies red blood cells. (lumbar puncture) C· It visualizes blood vessels. (CT scan) D· It measures oxygenation.
A
Which issue would the nurse prioritize when planning care for a patient in the acute phase of an ischemic stroke? A· Impaired breathing (ABC) B· Dysphagia C· Impaired verbal communication D· Muscle atrophy of paralyzed side
A
Which medical condition places a patient at a higher risk for an embolic stroke? A· Atrial fibrillation B· Atherosclerosis C· Cancer of the brain D· Anticoagulant therapy
A
Which modifiable risk factor for stroke would be most important for the nurse to include when planning a community education program? A· Hypertension B· Hyperlipidemia C· Alcohol consumption D· Oral contraceptive use
A
Which type of stroke is a patient at risk for if atrial fibrillation is untreated? A· Embolic stroke B· Thrombotic stroke C· Intracerebral hemorrhage D· Subarachnoid hemorrhage
A
Which lobe of the brain is affected if a patient has Broca's aphasia? A· Frontal lobe B· Parietal lobe C· Occipital lobe D· Temporal lobe
A (reasoning, planning, speech, movement, emotions & problem solving)
Which diagnostic tests are a priority for a patient who had a stroke and needs a cardiac assessment? Select all that apply. A· Chest x-ray B· Cardiac markers C· Electrocardiogram D· CT E· Complete blood count
A, B, C
A nurse is planning a community-based stroke awareness/prevention health fair. Which activities would be most helpful to include? Select all that apply. A· Smoking cessation B· Cholesterol screening C· BP screening D· Early warning signs of a stroke E· Education on food high in vitamin K F· Importance of taking aspirin daily if having a history of sinus tachycardia
A, B, C, D
Which staff would be included in the care team at a certified stroke center? Select all that apply. A· Radiologist B· Neurologist C· Registered nurse D· Radiologic technician E· Emergency physician (only activate the stroke team) F· Patient care technician
A, B, C, D
Which manifestations would the nurse expect to find in a patient who had a stroke and is having spatial-perceptual alterations. Select all that apply. A· Agnosia B· Apraxia C· Akinesia D· Expressive aphasia E· Homonymous hemianopsia
A, B, E
When reviewing a patient's chart, which risk factors would the nurse address in a teaching plan for this patient regarding stroke prevention? Select all that apply. A· Atrial fibrillation B· Walks once a week C· Quit smoking in 1984 D· History of breast cancer E· History of urinary tract infections F· Drinks three glass of red wine daily
A, B, F
Which tasks would the nurse delegate to unlicensed assistive personnel when planning care for a group of patients on a stroke unit? Select all that apply. A· Measuring and recording oral intake and urine/bowel output B· Screening patients for tissue plasminogen activator therapy C· Assessing neurologic status using the Glasgow Coma Scale D· Providing oral and lip care at least every two hours and PRN E· Placing equipment needed for seizure precautions in the patient's room F· Assisting with positioning the patient and turning the patient at least every two hours
A, D, E, F
The RN 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? A· "I will perform suctioning PRN." B· "I will discourage the patient from coughing." C· "I will encourage rapid breathing by the patient." D· "I will provide a small amount of food before the swallow evaluation."
A. "I will perform suctioning PRN." Rationale: Suctioning helps to remove secretions and clear the airway. Coughing should be encouraged in the patient because it removes secretions and reduces the risk of aspiration. Slow, deep breaths should be encouraged to help in airway clearance. Before doing a swallow evaluation, the patient should be kept NPO to reduce the risk of aspiration.
During the acute stage of a stroke, which intervention would be included in the plan of care for a patient experiencing aphasia? A· Ask simple yes-and-no questions. B· Limit verbal communication to reduce frustration. C· If the patient is unable to answer a question, divert eye contact to reduce embarrassment. D· If the patient does not answer immediately, ask the patient if he or she understands or needs the information repeated.
A. Ask simple yes-and-no questions.
A patient who experienced a stroke on the left side of the brain suddenly begins to cry while playing a card game. Which action would the nurse take? A· Distract the patient. B· Ask the patient what made him or her cry. C· Sit with the patient until he or she stops crying. D· Reassure the patient that there is nothing to cry about.
A. Distract the patient
Which information would be included when explaining to the relatives of a patient suspected of having a stroke about the importance of undergoing MRI? Select all that apply. A· It is helpful in identifying the likely causes of stroke. B· It measures oxygenation and temperature of the brain. C· It helps to differentiate between a stroke and any other brain lesion. D· It helps to measure blood flow through major vessels. (Doppler US) E· It evaluates the progression of a stroke. (CTscan)
A. It is helpful in identifying the likely causes of stroke. C. It helps to differentiate between a stroke and any other brain lesion. Rationale: MRI is a test that produces very accurate pictures of the brain and its arteries without x-rays or dyes. This test is useful for detecting a wide variety of brain and blood vessel abnormalities and can usually determine the area of the brain that is damaged by an ischemic stroke. It helps to identify likely causes of stroke and also to confirm diagnosis. MRI does not measure oxygenation and temperature of the brain. It also does not measure the blood flow through major vessels; cerebral angiography and intracranial Doppler ultrasonography can be done to measure the blood flow in cerebral blood vessels. MRI does not evaluate the progression of a stroke; this can be done by serial CT scans.
How would the nurse communicate with the patient who has aphasia after suffering from a stroke? Select all that apply. A· Make use of gestures. B· Present only one thought at a time. C· Do not interrupt the patient if he or she is taking too long to communicate. D· Pretend to understand the patient even if he or she does not make sense. E· Keep communicating, even if the patient is upset, to help the patient to change his or her mood.
A. Make use of gestures. B. Present only one thought at a time. C. Do not interrupt the patient if he or she is taking too long to communicate.
Which responsibilities would the nurse delegate to unlicensed assistive personnel when caring for a patient who has suffered from a stroke this morning? Select all that apply. A· Measure and record urine output. B· Assess the patient's ability to swallow. C· Perform passive and active range-of-motion exercises. D· Administer scheduled anticoagulant and antiplatelet medications. E· Screen patients for contraindications for tissue plasminogen activator (tPA).
A. Measure and record urine output. C. Perform passive and active range-of-motion exercises.
A patient has been given an infusion of tissue plasminogen activator (tPA) for ischemic stroke. Which actions would the nurse take for 24 hours post treatment? Select all that Apply. A· Monitor vital signs. B· Use anticoagulants. C· Start pain medication. D· Check BP. E· Start IV glucose.
A. Monitor vital signs. D. Check BP.
While assessing a patient who sustained a hemorrhagic stroke, the nurse finds that the patient has decreased gag, cough, and swallowing reflexes. Which complication would the nurse expect in the patient? A· Risk of aspiration B· Unilateral neglect C· Impaired physical mobility D· Decreased intracranial adaptive capacity
A. Risk of aspiration Rationale: Decreased gag, cough, and swallowing reflexes may increase the risk of aspiration in the patient. Unilateral neglect is related to visual defects. Impaired physical mobility indicates neuromuscular and cognitive impairment. Decreased intracranial adaptive capacity is related to a decreased cerebral perfusion pressure.
Which nursing intervention would the nurse plan to provide for a patient who had a right hemispheric stroke? A· Safety measures B· Patience with communication C· Mobility assistance on the right side D· Placing food in the left side of the patient's mouth
A. Safety measures Rationale: A patient with a right-hemispheric stroke has spatial-perceptual deficits, tends to minimize problems, has a short attention span, is impulsive, and may have impaired judgment. Safety is the biggest concern for this patient.
Which interventions would be included in the plan of care to prevent skin breakdown in a patient with paralysis due to a stroke? Select all that apply. A· Using emollients on the skin B· Changing the patient's position every two hours (every 30 minutes) C· Providing good skin care and hygiene D· Using a special mattress for pressure relief D· Using minimal pillows while the patient is on bed rest
A. Using emollients on the skin C. Providing good skin care and hygiene D. Using a special mattress for pressure relief Rationale: Interventions for preventing skin breakdown include using emollients (moisturizers) applied to a patient's dry skin, providing good skin care and hygiene, and using special mattresses to prevent pressure to the paralyzed area. The position of a paralyzed patient should be changed every 30 minutes (not two hours) to prevent damage to the epidermis and dermis, manifested as permanent redness of the skin. Early mobility should be encouraged (not bed rest), and the use of pillows under extremities reduces pressure on the heels.
Which action would help a nurse to communicate better with a stroke patient with aphasia? A· Utilizing touch B· Nodding at all times C· Talking as if to a child D. Speaking loudly and firmly
A. Utilizing touch Rationale: Touching may be the only way a patient with aphasia can express feelings.
Which interventions would be included in the acute care of a stroke patient? Select all that apply. A· Monitor urine output. B· Monitor the blood sugar level. C· Ensure adequate fluid intake. D· Start 5% dextrose IV. E· Use medications to lower the BP.
A· Monitor urine output. B· Monitor the blood sugar level. C· Ensure adequate fluid intake.
A nurse is explaining the National Institutes of Health Stroke Scale (NIHSS) to a student nurse. Which statement indicates that the student nurse understands the purpose of performing the NIHSS? A· "The NIHSS helps to prevent a second stroke." B· "The NIHSS measures the severity of a stroke." C· "The NIHSS is used primarily for research data collection." D. "The NIHSS is an invasive procedure that measures stroke severity.
B
If blood flow to the brain is interrupted, how quickly does cellular death occur? A· 2 minutes B· 5 minutes C· 30 minutes D· 30 seconds
B
The nurse finds that the patient is unable to recognize familiar objects after a stroke. Which term would the nurse chart in the patient's medical record? A· Alexia (difficult reading) B· Agnosia C· Aphasia D· Agraphia (difficult writing)
B
Which clinical manifestation is associated with a left-hemispheric stroke? A· Impulsivity B· Impaired speech C· Left-side neglect D· Short attention span
B
Which diagnostic test determines cerebral blood flow? A· Echocardiography B· Cerebral angiography (find blood vessel blockage in head and neck) C· Magnetic resonance angiography D· CT angiography
B
Which information would the nurse include in a teaching plan about the onset of embolic stroke? A· Embolic stroke rarely recurs. B· Embolic stroke occurs rapidly. C· Embolic stroke renders the patient unconscious. D· It is common to have a warning sign with an embolic stroke.
B
Which rationale is accurate regarding why IV solution with glucose and water would be avoided in a patient who sustained an ischemic stroke? A· It decreases urine output. B· It increases cerebral edema. (hypotonic) C· It decreases intracranial pressure. D· It maintains electrolytes.
B
While doing a neurologic assessment of a patient who sustained a thrombotic stroke, the nurse records the score of a patient as 40 on a National Institutes of Health Stroke Scale (NIHSS). Which interpretation does this score indicate? A· Minor stroke B· Severe stroke C· Moderate stroke D· No stroke symptoms
B
Which cardiac manifestations will the nurse notify the health care provider about in a patient who suffered a severe closed head injury? Select all that apply. A· Tachycardia (fluid volume deficit) B· Systolic hypertension C· Systolic hypotension (fluid volume deficit) D· Widening pulse pressure E· Bradycardia with a full and bounding pulse
B, D, E
Which instructions would the nurse give a patient about methods to reduce the risk of having a stroke? Select all that apply. A· Limit fluid and fiber intake. B· Eat a diet low in saturated fats. C· Decrease level of physical exercise. D· Maintain a normal BP. E. Limit consumption of alcohol to moderate levels.
B, D, E
A patient suspected of having a subarachnoid hemorrhage is scheduled to undergo transcranial Doppler (TCD). Which information about this procedure would the nurse provide the patient and the patient's family? Select all that apply. A· "It is an invasive procedure." B· "It is effective in detecting microemboli." C· "It requires a small dose of contrast media." D· "It provides visualization of cerebral blood vessels." E· "It measures the velocity of blood flowing through major vessels."
B, E
Which assessment would the nurse teach a patient to report as part of the warning signs of stroke, using the mnemonic FAST? A· Footdrop B· Arm strength C· States disoriented D· Facial drooping
D
A patient has left-sided hemiplegia following an ischemic stroke that was experienced four days earlier. How would the nurse best promote the health of the patient's integumentary system? A· Position the patient on the weak side most of the time. B· Alternate the patient's positioning between supine and side-lying. C· Avoid the use of pillows to promote independence in positioning. D· Establish a schedule for the massage of areas where skin breakdown emerges.
B. Alternate the patient's positioning between supine and side-lying. Rationale: A position change schedule should be established for patients who had a stroke. An example is side-back-side, with a maximum duration of two hours for any position. The patient should be positioned on the weak or paralyzed side for only 30 minutes. Pillows may be used to facilitate positioning. Areas of skin breakdown should never be massaged.
Which aspects of the medical history of a female patient are risk factors for stroke? Select all that apply. A· Chronic low back pain B· Current use of high-dose oral contraceptives (↑ progestin & estrogen is a risk) C· History of long-standing hair loss D· History of migraine headaches with aura E· Past employment involving exposure to chemical dyes
B. Current use of high-dose oral contraceptives D. History of migraine headaches with aura Rationale: Oral contraceptive pills with high levels of progestin and estrogen increase a woman's chance for experiencing stroke. People with migraine are at an increased risk of or stroke, although the mechanism for the increased risk in women with migraines remains unknown. Low back pain, hair loss, and past employment working with dyes do not increase the risk for stroke.
The nurse assesses a patient experiencing visual disturbances, difficulty swallowing, and decreased level of consciousness with a BP of 280/180 mm Hg. Which action by the nurse is a priority? A· Call the stroke team. B· Ensure patent airway. C· Perform pulse oximetry. D· Position head in midline.
B. Ensure patent airway. Rationale: Symptoms such as decreased level of consciousness, visual disturbances, hypertension, and difficulty in swallowing indicate a stroke. The first, most important intervention provided to a patient who has sustained a stroke is ensuring a patent airway and preventing airway obstruction. Airway obstruction for few minutes results in death. After ensuring patent airway, the stroke team should be notified. Hypoxia is common in a stroke; therefore pulse oximetry should be performed. The head is positioned midline to improve venous drainage.
A nurse is measuring the BP of a hypertensive obese patient who has been admitted to the hospital for increased blood glucose levels. While he or she is speaking, the nurse notes that the patient has suddenly started mumbling and is unable to articulate words. Which action would the nurse take? A· Refer the patient to a speech therapist. B· Treat this as an emergency and call the health care provider. C· Ensure the patient that he or she should not worry about the illness. D· Ask the patient to protrude the tongue to test the hypoglossal nerve.
B. Treat this as an emergency and call the health care provider.
A patient was brought to the emergency department with a sudden onset of a severe headache different from any other headache previously experienced. Which type of stroke is most likely occurring based on these symptoms? A· Embolic stroke B· Thrombotic stroke C· Hemorrhagic stroke (headache is common) D· Transient ischemic attack (TIA)
C
A patient with a history of rheumatic heart disease arrives in the emergency department and informs the nurse of sudden loss of strength in the left arm without pain. The patient is unable to lift the arm and says that it "just fell." Which condition would the nurse suspect? A· Myopathy B· Fibromyalgia (stiffness and pain in a particular part of the body) C· Embolic stroke D· Carpal tunnel syndrome
C
Which condition presents with a sudden onset of a headache, vomiting, and decreased level of consciousness? A· Embolic stroke B· Brain infarction C· Cerebral edema D· Hemorrhagic stroke
D
An experienced nurse is teaching a novice nurse about interventions for a patient with a stroke. Which statement by the novice nurse indicates a need for further teaching? A· "I should maintain a calm and relaxing environment." B· "I should refrain from scolding the patient during an emotional outburst." C· "I should refrain from distracting the patient during a sudden emotional outburst." D· "I should educate the patient and the family about emotional outbursts after stroke."
C
How would the nurse explain a transient ischemic attack (TIA) to the spouse of a patient who just had a TIA? A· It is usually neurologically damaging. B· It is a signal of progressive brain damage. C· It can be a warning of an impending stroke. (occurs hours or days before) D· It is nothing to be concerned about because it is not a stroke.
C
The nurse preparing to administer IV recombinant tissue plasminogen activator (tPA) to a patient status post-ischemic stroke prioritizes which action as needing to be done first? A· Administer baby aspirin. B· Verify the patency of the IV. C· Assess for recent bleeding or surgeries. D· Document the patient's estimated weight.
C
The patient was exhibiting symptoms of a stroke for 45 minutes before the symptoms resolved. Which condition may this patient have experienced? A· Embolic brain stroke (clot to the brain) B· Acute brain infarction (cell death occurs) C· Transient ischemic attack D· Subarachnoid hemorrhage
C
Which assessment is most important to conduct on a patient presenting with symptoms of an acute ischemic stroke? A· Basic metabolic profile B· Electrocardiogram C· Pupillary response D· Swallowing function
C
Which deficit associated with the anterior cerebral artery would the nurse expect to find in a patient who had a stroke? A· Diplopia B· Dysphagia C· Rooting reflex D. Visual hallucination
C
Which deficit is associated with left-hemispheric stroke? A· Overestimation of physical abilities B· Difficulty judging position and distance C· Slow and possibly fearful performance of tasks D· Impulsivity and impatience at performing tasks
C
Which factor improves cerebral blood flow? A· An increase in blood viscosity B· A decrease in carbon dioxide levels C· An increase in hydrogen ion concentration D· A high partial pressure of arterial oxygen
C
Which finding is consistent with a left-hemispheric stroke? A· Impaired judgment B· Unilateral weakness of the left extremities C· Unilateral weakness of the right extremities D· Spatial-perceptual deficits
C
Which ethnic group has the highest incidence of stroke? A· Asians B· Mexicans C· Caucasians D. Blacks
D
Which information is most important for the nurse to include when teaching a patient and the family about the administration of warfarin? A· Avoid having international normal ratio (INR) tested if illness with fever is present. B· Do not drink more than one or two glasses of grapefruit or cranberry juice a day. C· Alert the health care provider if a fall or head injury is sustained, even if there are no symptoms. D· Call the health care provider for excessive bruising while on warfarin.
C
Which type of stroke correlates with the clinical manifestations of a severe headache, hypertension, vomiting, dysarthria, and eye-movement disturbances? A· Embolic stroke B· Thrombotic stroke (↓ level of consciousness in the first 24 hours) C· Intracerebral hemorrhage D· Subarachnoid hemorrhage (stiff neck and cranial neve deficits)
C
Which findings support the use of thrombolytic agents for a patient diagnosed with a stroke? Select all that apply. A· The onset of symptoms was six hours ago. (too long) B· The patient had a hip replacement one week ago. (no surgery in the last two months) C· There has been no head trauma for three months. D· The patient's BP is 180/100 mm Hg. E· There is a recent history of gastrointestinal (GI) bleeding. F· The CT scan is clear of hemorrhage.
C, D, F
A patient being discharged from the hospital after a stroke looks at an old photograph and breaks down, crying inconsolably. Which statements by the nurse are appropriate to say to the patient and the family? Select all that apply. A· "Leave the patient alone for some time." B· "Try to find out why the patient is crying." C· "Frustration and depression are common during the first year after stroke." D· "Do not communicate with the patient on topics that make the patient cry." E· "Be patient during recovery and do not complain about these involuntary behaviors."
C, E
Which nursing intervention would be included in the plan of care for a patient who is admitted with a stroke and is complaining about having liquid stools? A· Administering enemas B· Administering psyllium C· Checking for stool impaction D· Discouraging physical activity
C. Checking for stool impaction Rationale: Stool impaction is the development of a solid immobile mass of fecal matter in the rectum, which may result in liquid stool. Therefore the nurse should assess for this first. An enema helps to facilitate bowel movements but should be avoided because it increases the intracranial pressure. Psyllium is a form of fiber used to increase the solid mass in the intestine so that the feces can pass easily. Physical activity stimulates bowel function, so the nurse should encourage the patient to perform physical activity.
Which action can the nurse delegate to the unlicensed assistive personnel (UAP) to reduce fatigue for a patient recovering from a stroke at mealtimes? A· Feed the patient the meal. B· Provide water during the meal. C· Cut up the meat for the patient. D· Place the head of the bed at 30 degrees.
C. Cut up the meat for the patient Rationale: The nurse should instruct the UAP to cut up the meat at mealtimes and to assist with eating as needed. The ability to drink water during the meal may be limited if the patient has problems swallowing, but this will not address fatigue. Placing the head of the bed at 30 degrees is not high enough for eating and will not reduce fatigue during the meal. Feeding this patient reduces independence and should be avoided as the first action
When feeding a patient with a stroke on the left side, in which position would the nurse place the patient? A· Right lateral position B· Low Fowler's position C· High Fowler's position D· Trendelenburg's position
C. High Fowler's position Rationale: A person in a Fowler's position is sitting straight up or leaning slightly back. The legs may either be straight or bent. A high Fowler's position is sitting upright. This helps in feeding, as well as swallowing, for the patient. Sitting in a chair with the head flexed forward also serves a similar purpose. Low Fowler's, Trendelenburg's, and right lateral positions are not appropriate for feeding.
Which behavior would be exhibited by a patient who has suffered a right-brain stroke? A· Very cautious B· Difficulty with words C· Impulsive and impatient D· Accomplishes tasks quickly
C. Impulsive and impatient Rationale: A patient who has suffered a stroke on the right side of the brain will behave impulsively and act impatiently. A left-brain stroke survivor is aware of the deficiency and failure in mental functioning and is very cautious. After a stroke, a patient will be much slower while undertaking actions. Survivors of left-brain damage will experience communication problems and have difficulty with words.
Which food would be included in the diet for a patient who had a stroke and has dysphagia? A· Milkshakes B· Chicken soup C· Mashed potatoes D· Pureed cooked rice
C. Mashed potatoes Rationale: Patients who had a stroke and have dysphagia have difficulty chewing and swallowing. Thus the nurse would include mashed potatoes because the food is easy to swallow and provides enough texture.
A patient with a known history of hypertension presents to the emergency department with the complaint of sudden severe headache with no known cause. Which intervention would the nurse do first? A· Perform eye examination. B· Perform reflex examination. C· Obtain orders and send the patient for a CT scan. D· Obtain orders for administering antihypertensives.
C. Obtain orders and send the patient for a CT scan.
Which intervention would the nurse delegate to the experienced unlicensed assistive personnel (UAP) when working with a patient who had a stroke? A· Suction oral pharynx PRN. B· Assess orientation every four hours. C· Perform passive range-of-motion exercises to flaccid extremities. D· Ensure gag reflex is intact before offering fluids or food.
C. Perform passive range-of-motion exercises to flaccid extremities. Rationale: After appropriate training and evaluation, the UAP can perform passive-range of-motion exercises to patients who have had a stroke. Suctioning the oral pharynx, assessing the gag reflex, and level of orientation requires more advanced skills and evaluation than is in the scope of practice of the UAP.
Which action would be beneficial to a patient with a right-brain stroke? A· Wear shoes when out of bed. B· Arrange food on the left side. C· Remove clutter and obstacles. D· Give directions nonverbally.
C. Remove clutter and obstacles Rationale: A right-brain stroke survivor is at a higher risk for injury due to mobility issues. Therefore all clutter and obstacles should be removed, and proper lighting should be provided. Patients should wear nonslip and skid resistant socks when out of bed to prevent falls. A right-brain stroke patient will tend to neglect the left side of the body; food should not be placed on the left side. All directions for activities should be given verbally to facilitate comprehension.
Which expected outcome would be included in the plan of care for a patient who had a stroke and is experiencing residual expressive aphasia? A· The patient will verbalize plans for rehabilitation. B· The patient will be satisfied with the care environment. C· The patient will demonstrate alternative communication techniques. D· The patient will demonstrate understanding that the aphasia is permanent.
C. The patient will demonstrate alternative communication techniques.
Which information is most important for the nurse to provide when educating a patient on the administration of baby aspirin? A· Drink a full glass of water with each dose. B· Take the aspirin at the same time each day. C· Do not crush or chew enteric-coated tablets. D· Call the health care provider if hearing changes.
D
Which nursing interventions would assist a patient who had a stroke and is frustrated by mobility problems? Select all that apply. A· Ask the patient to maintain bed rest. B· Probe the patient about the reason for frustration. C· Allow family and friends to visit the patient more often. D· Speak to the patient in a calm, caring manner to reduce frustration. E· Help the family understand that frustration is common in the first year after a stroke
C· Allow family and friends to visit the patient more often. D· Speak to the patient in a calm, caring manner to reduce frustration. E· Help the family understand that frustration is common in the first year after a stroke.
After suffering a head trauma, a patient with a stiff neck and cranial nerve deficits is at risk for which complication? A· Embolic stroke (atrial fibrillation) B· Thrombotic stroke C· Intracerebral hemorrhage D· Subarachnoid hemorrhage
D
At which rate must blood flow in the brain be maintained for normal functioning? A· 200 to 400 mL/min B· 400 to 600 mL/min C· 650 to 750 mL/min D· 750 to 1000 mL/min
D
Which mechanism protects the brain and promotes its functioning? A· Collateral circulation B· Intracranial pressure C· Neurologic metabolism D. Cerebral autoregulation
D
Which neurologic factor would the nurse assess and record for a patient who had a stroke? A· Speech (motor functions assessment) B· Mobility (motor functions assessment) C· Respiratory function (motor functions assessment) D· Level of consciousness (to see if it is a neurologic finding)
D
Which risk factors would the nurse include in a teaching plan when instructing a patient about modifiable risk factors for stroke? A· Age B· Gender C· Heredity D· Smoking
D
Which statement is accurate about the recommendations for BP management after an ischemic stroke? A· A lower BP is a protective response to maintain cerebral perfusion. B· The BP must be lower than 160/70 mm Hg to receive fibrinolytic agents. C· Elevated BPs are expected after a stroke, and drug therapy should be initiated. D· Drugs to lower BP are recommended if the BP is 220/120 mm Hg or higher.
D
The patient recovering from a stroke who is confined to bed for most of the day is at risk for which condition? A· Fatigue B· Malnutrition C· Dehydration D· Constipation
D (due to weak abdominal muscles)
A nurse is teaching a group of caregivers the warning signs of stroke. Which type of assessment data obtained from the patients would the nurse teach the caregivers to consider an emergency? Select all that apply. A· The patient is unable to sleep. B· The patient cannot hear properly. C· The patient has a loss of appetite. D· The patient suddenly has blurry vision. E· The patient suddenly has slurred speech.
D, E
Which tests would be done for screening patients who are at risk for a stroke? Select all that apply. A· BP B· Routine urinalysis C· Stool examination D· Blood sugar level E· Serum cholesterol
D, E
The RN 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? A. · "I will speak in a normal tone with the patient." B· "I will frame questions in a yes-or-no format." C· "I will not pretend to understand the patient if I do not." D· "I will try to force communication with the patient if the patient is upset."
D. "I will try to force communication with the patient if the patient is upset." Rationale: Communication should not be forced if the patient is upset because anxiety worsens aphasia. Communication with the patient should be in a normal tone of voice because the patient should not feel as if they are spoken to like a child. Questions should be framed in a yes-or-no format to make communication easier for the patient. The nurse should not pretend to understand the patient. Instead, the patient should be encouraged to use nonverbal modes of communication.
A nurse is admitting a patient with a thrombotic stroke. The patient is NPO but is requesting a drink of water. Which response by a nurse is appropriate? A· "You can have a couple of ice chips to wet your mouth." B· "A barium swallow test is required for stroke patients before giving PO fluids." C· "We need to keep you NPO in case a procedure needs to be performed today." D· "It is not safe to allow you to have anything by mouth until a swallow assessment can be performed."
D. "It is not safe to allow you to have anything by mouth until a swallow assessment can be performed." Rationale: Stroke patients are at high risk for aspiration pneumonia.
A patient presenting with stroke symptoms is being considered for fibrinolytic therapy. Which assessment data would be important to communicate promptly to the prescribing health care provider? A· Presence of indwelling urinary catheter B· Removal of soft-tissue tumor from the back three weeks ago C· History of transient ischemic attack (TIA) six months ago D· Colonoscopy due to blood in the stools one week ago
D. Colonoscopy due to blood in the stools one week ago
A patient underwent aneurysm clipping six hours ago for subarachnoid hemorrhage and is being treated with nimodipine. While examining the patient, the nurse finds that the pulse of the patient is 50 beats per minute (beats/min) and the BP is 90/60 mm Hg. Which action would the nurse take for this patient? A· Encourage intake of fluids orally. B· Monitor BP every half hour. C· Start IV fluids to increase blood volume. D· Hold the medication and contact the health care provider.
D. Hold the medication and contact the health care provider. Rationale: Nimodipine is a calcium channel blocker that is given to patients with subarachnoid hemorrhage to decrease the effects of vasospasm and to minimize cerebral damage. Nimodipine lowers the BP; therefore before administration, it is important to assess the BP and apical pulse. If the pulse and BP drop (pulse is less than 60 beats per minute and systolic BP is less than 90 mm Hg), then the medication should be stopped and the health care provider should be contacted immediately. The nurse should not start IV fluids without contacting the health care provider first. The BP may be monitored more frequently if they are in intensive care or unstable. The patient may be NPO or unable to have oral fluids at this point.
Which rationale is accurate for why the use of video games would be included in the plan of care for a patient who sustained a stroke? A· The patient's anxiety can be improved. B· The patient's aphasia can be improved. C· The patient's hemiplegia can be improved. D· The patient's motor skills can be improved.
D. The patient's motor skills can be improved. Rationale: Video games can improve motor skills because the brain, nervous system, and muscles work together while playing. Video games are ineffective in improving anxiety, aphasia, or hemiplegia.
Which intervention would the nurse take when communicating with a patient suffering from aphasia following a stroke? A· Present several thoughts at once so that the patient can connect the ideas. B· Ask open-ended questions to provide the patient the opportunity to speak. C· Finish the patient's sentences to minimize frustration associated with slow speech. D· Use simple, short sentences accompanied by visual cues to enhance comprehension.
D. Use simple, short sentences accompanied by visual cues to enhance comprehension. Rationale: When communicating with a patient with aphasia, the nurse should present one thought or idea at a time. Ask questions that can be answered with a "yes," "no," or simple word. Use visual cues, and allow time for the individual to comprehend and respond to conversation. Presenting several thoughts at once would overwhelm the patient. Asking open-ended questions would be difficult for the patient to answer. Do not finish the patient's sentences because it will cause frustration on his or her part, and the nurse doesn't know for sure what the answer is
Which food items would be included in the diet plan for a patient being discharged from the hospital after recovering from a stroke? Select all that apply. A· Pizza B· French fries C· Cheeseburger D· Grilled chicken E· Vegetable soups
D· Grilled chicken E· Vegetable soups Rationale: A patient who has recovered from a stroke should follow dietary restrictions. The diet should be low in fats; hence grilled chicken is preferred to fried chicken. A diet that is high in fruits and vegetables reduces the risk for stroke. French fries, cheeseburgers, and pizzas are high in fat and should be avoided.
Which information would be given to the patient with a history of transient ischemic attacks and has been prescribed aspirin? Select all that apply. A· It is only a pain medication. B· It is used to break up clots. C· It is okay to lower the dose if you feel well. D· It is pain medication and an antiplatelet agent. E· It may cause bleeding, which should be reported immediately.
D· It is pain medication and an antiplatelet agent. E· It may cause bleeding, which should be reported immediately. Rationale: Patients should know that aspirin is not only a pain medication but also an antiplatelet agent. Aspirin may cause bleeding if taken for a long duration, which should be reported to the health care provider. It helps to prevent clots by inhibiting platelets from sticking together. The patient should not increase or decrease the dose of aspirin without consulting their health care provider.
Which are primary methods of preventing a stroke? Select all that apply. A· Healthy diet B· Regular exercise C· Stroke rehabilitation D· Breast self-examination E· Knowing the signs of stroke F. Management of BP
Which are primary methods of preventing a stroke? Select all that apply. A· Healthy diet B· Regular exercise C· Stroke rehabilitation D· Breast self-examination E· Knowing the signs of stroke F. Management of BP
