Med-surg CH. 45

Which abnormality occurs during embryonic development?

Arteriovenous malformation

Which patient complication is most commonly associated with dysphagia?

Aspiration

A patient who sustained a transient ischemic attack (TIA) is admitted to emergency department. The nurse is teaching the student nurse about methods to prevent another TIA. Which statement made by the student nurse indicates a need for further teaching?

'The patient should be placed on a totally liquid diet.'

The nurse is teaching a group of older adults about transient ischemic attack (TIA). Which statement made by a participant indicates a need for further teaching regarding TIAs?

'There is a loss of central vision.'

A family member of a patient who experienced a stroke is anxious and says to the nurse, "Something is the matter with Grandpa. All he does is cry!" Which response by the nurse is best at this time?

'He is emotionally labile and may have this behavior for some time.'

A patient with an acute ischemic stroke is admitted to the emergency department. The nurse is teaching a student nurse about potential medication the patient may need. Which statement made by the student nurse show ineffective learning?

'A programmable pump should be used to deliver an initial dose of 120 mg over 2 hours with 10% of the dose given intravenously.'

The daughter of a patient who has had a stroke asks the nurse for additional resources. What is the nurse's best response?

'Go to the National Stroke Association website.'

How many categories are on the national institute of health stroke scale (NIHSS)?

11

Which ethnic group has the highest prevalence of stroke over others?

American Indians and Alaskan Natives

A patient recovering from a stroke reports double vision that is preventing the client from effectively completing activities of daily living (ADLs). How does the nurse help the client compensate?

Covers the affected eye

The nurse is assessing a patient admitted with a stroke. What assessment finding would indicate that the patient experienced a stroke to the right hemisphere?

Denial of the illness

A patient experienced a stroke that caused damage to Broca's area. The nurse expects the patient to experience what phenomenon as a result of this injury?

Expressive aphasia

What factor has been shown to delay stroke intervention?

Gender

Which type of stroke is caused by aneurysm or hypertension?

Hemorrhagic stroke

Which type of stroke shows interrupted vessel integrity and bleeding that occurs in to the brain tissue or into the subarachnoid space?

Hemorrhagic stroke

Which potential disorder should be ruled out before a patient's level of consciousness is attributed to stroke?

Hypoglycemia

A 70-year-old woman brought to the emergency department is diagnosed with acute ischemic stroke with a NIH Stroke Scale score of 20. A family member reports last seeing the patient as normal (LSN) 3.5 hours before evaluation. The patient has an INR of 1.4. The nurse anticipates that the patient will not be eligible for fibrinolytic therapy for which reason?

INR 1.4

The patient is admitted with a diagnosis of stroke in the right cerebral hemisphere. Upon assessment, which primary deficit does the nurse expect to find?

Impaired proprioception

A patient is brought to the emergency department with sudden onset of right-sided paralysis and difficulty speaking. A family member is worried that these symptoms will be permanent. Based on the patient's symptoms, the nurse anticipates which outcome?

Improve over several days

A patient has been admitted with a diagnosis of stroke (brain attack). The nurse suspects that the patient has had a right hemisphere stroke because the patient exhibits which symptoms?

Impulsiveness and smiling

Which nursing intervention takes priority in a patient with dysphagia?

Keep the patient on strict NPO status until he or she can swallow safely.

A patient is brought to the emergency department with aphasia and right-sided hemiplegia. The nurse suspects a stroke in which area of the brain?

Left cerebral hemisphere

A patient is admitted with a stroke (brain attack). Which tool does the nurse use to facilitate a focused neurologic assessment of the patient?

National institutes of Health Stroke Scale (NIHSS)

A patient is having difficulty understanding spoken and written words and is saying made-up words and meaningless speech. What would be the possible reason behind the patient's condition?

Receptive aphasia

The nurse is caring for a patient with a confirmed thrombotic stroke, whose onset of symptoms began 2 hours earlier. The nurse expects the health care provider to prescribe the administration of which drug?

Recombinant tissue plasminogen activator

A patient is receiving IV administration of recombinant tissue plasminogen activator (rtPA) therapy. Which sign/symptom alerts the nurse that the infusion should be discontinued?

Report of headache

The nurse is caring for a patient one day after the patient suffered a stroke. The patient is fully alert and has weakness of the right side of the body. Which assessment finding indicates an increasing intracranial pressure (ICP)?

The patient is no longer oriented to place

Which type of stroke syndrome would most likely cause a coma in a patient?

Vertebrobasilar artery strokes

What symptoms are present with a transient ischemic attack (TIA)? Select all that apply.

Vertigo Aphasia Blurred vision

A patient is eating a soft diet while recovering from a stroke. The client reports food accumulating in the cheek of the affected side. What is the nurse's best response?

'Let's see if the speech-language pathologist can help.'

A patient who has experienced symptoms consistent with a transient ischemic attack (TIA) refuses to go to the emergency department because the symptoms resolved at home. Which statement would the clinic nurse make over the phone to convince the patient to seek care?

'Your condition could progress to a stroke.'

Alteplase should be given within how many hours from the onset of symptoms of stroke?

4.5

Which factors contraindicate administering alteplase more than three hours after stroke onset? Select all that apply.

Age older than 80 years History of both diabetes and stroke Use of warfarin or other anticoagulants Imaging evidence of middle cerebral artery involvement

Which group is at the highest risk for stroke?

Alaskan native men

Nursing action to help prevent increased intracranial pressure after a stroke include which activity?

Careful monitoring of temperature

Abuse of which substance most likely to result in hemorrhagic stroke?

Cocaine

A patient is admitted to the emergency department for a stroke. Which intervention helps provide proper care for the patient?

Maintain the head of the patient in a midline, neutral position.

Which stroke syndrome has clinical features such as perpetual, spatial, and visual field deficit?

Middle cerebral artery stroke

During assessment, the nurse notes that a patient cannot identify the month, cannot state his or her age correctly, the arm and leg drift when elevated, and that the patient is silent when asked to identify common items. The nurse should document what total score in the patient's medical record based on the National Institutes of Health Stroke Scale (NIHSS)? Record your answer using a whole number.

6

A patient weighing 165 pounds will begin receiving recombinant tissue plasminogen activator (rtPA) to treat an ischemic stroke. The nurse expects an order to administer how many milligrams of rtPA in the first minute of the infusion? Record your answer using two decimal places. Use a leading zero if applicable. ___ mg

6.75

The nurse assesses a patient and notes partial hemianopia, ataxia in the right limb only, and no auditory comprehension. Painful stimulation is needed for the patient to make movements. Based on the National Institutes of Health Stroke Scale (NIHSS), what is the total score for this patient?

7

A patient hospitalized for hypertension presses the call light and reports "feeling funny." When the nurse gets to the room, the patient is slurring words and has right-sided weakness. What does the nurse do first?

Assesses airway, breathing, and circulation

A patient has been admitted to the hospital with symptoms of an embolic stroke. What etiologic factor in the patient's history places the patient at particular risk for this type of stroke?

Atrial fibrillation

The nurse is teaching a patient and family about home care after a stroke. Which statement made by the patient's spouse indicates a need for further teaching?

'I should spend all my time with my husband in case I'm needed.'

The nurses is teaching the spouse and patient who has had a brain attack (cerebrovascular accident) about rehabilitation. Which statement by the spouse demonstrates understanding of the nurse's instruction?

'The rehabilitation therapist will help identify changes needed at home.'

How much time will it take for the symptoms of transient ischemic attack to resolve?

30 to 60 minutes

The nurse is evaluating the collaborative care of a client with traumatic brain injury (TBI). What is the most important goal for this client?

Achieving the highest level of functioning

The nurse receives a patient in the emergency department (ED) who experienced a stroke. The patient is alert and requests something to eat from the nurse. Which is the best action the nurse can take?

Assess the swallowing ability of the patient

A patient diagnosed with a stroke is receiving recombinant tissue plasminogen activator (rtPA) through one intravenous line. The nurse discovers that the second line has infiltrated and removes it. The insertion site continues to bleed even after the nurse applies pressure on it. What is the priority nursing action?

Discontinue the rtPA infusion

A patient has a history of deep vein thrombosis (DVT) in the lower leg. The patient arrives at the emergency department due to fears of having stroke. Given this history, what type of stroke might the nurse first suspect?

E

A patient is receiving recombinant tissue plasminogen activator (rtPA) for an acute ischemic stroke. What nursing intervention does the nurse perform first to properly take care of the client?

Ensure that the prescribed follow-up computed tomography (CT) scan is done after treatment is completed and before starting antiplatelet drugs

Which action by unlicensed assistive personnel (UAP) in caring for a patient after a stroke requires immediate intervention by the nurse?

Gently pulling on a patient's flaccid arm to assist the patient up in bed

The nurse is obtaining a history on a patient who has had several transient ischemic attacks. Which risk factor in this patient's history cannot be changed with appropriate management of care?

Head trauma

The nurse is providing discharge teaching to a patient who had a carotid stent placement. The nurse instructs the patient to contact the health care provider at the occurrence of which symptoms? Select all that apply.

Headache Muscle weakness Neck swelling Severe neck pain

Which initial site is the most common source of emboli for those experiencing embolic stroke?

Heart

Which does the nurse teach the patient is a modifiable risk factor for stroke?

Obesity

Which substances does the brain require continuously because the brain does not have the ability to store them? Select all that apply.

Oxygen Glucose

Which are risk factors for stroke? Select all that apply.

Smoking High blood pressure Use of oral contraceptives Previous stroke or transient ischemic attack (TIA)

A patient has experienced a right-hemisphere stroke. What is an important nursing action while caring for this patient?

Stand on the patient's left side when talking to increase the visual field

what type of complication would a patient with the condition depicted in the image be at risk for developing?

Subarachnoid hemorrhage

The emergency room nurse is assessing a patient who presents with a stroke. The nurse finds that the patient shows perseveration, loss of deep sensation, and decreased touch sensation. What should the nurse infer from these symptoms?

The patient had a posterior cerebral artery stroke

The laboratory results for a patient who sustained a stroke shows the presence of proteins in the cerebrospinal fluid. What should the nurse infer from the reports?

The patient had an embolic thrombotic stroke.

A patient in the emergency department (ED) has slurred speech, confusion, and visual problems, and has been having intermittent episodes of worsening symptoms. The symptoms have a gradual onset. The patient also has a history of hypertension and atherosclerosis. What dose the nurse suspect the the patient is probably experiencing?

Thrombotic stroke