NU371 PrepU: Management of Patients with Cerebrovascular Disorders

A client is prescribed sumatriptan for the treatment of migraine headache. Which client statement would indicate a need for additional teaching from the nurse? a) "I use this to prevent migraines." b) "I take this when I get a headache." c) "It constricts the blood vessels in my head." d) "It alleviates my sensitivity to light and sound."

a) "I use this to prevent migraines." - Sumatriptan is a serotonin receptor agonist that stimulates serotonin receptors in the brain and causes vasoconstriction of the cerebral arteries and reduce/eliminate headaches and other symptoms associated with migraines. Sumatriptan is used during an attack and is not indicated for preventative migraine therapy.

The provider diagnoses the patient as having had an ischemic stroke. The etiology of an ischemic stroke would include which of the following? a) Cardiogenic emboli b) Cerebral aneurysm c) Arteriovenous malformation d) Intracerebral hemorrhage

a) Cardiogenic emboli - Aneurysms, hemorrhages, and malformations are all examples of a hemorrhagic stroke. An embolism can block blood flow, leading to ischemia.

Which insult or abnormality can cause an ischemic stroke? a) Cocaine use b) Arteriovenous malformation c) Trauma d) Intracerebral aneurysm rupture

a) Cocaine use - Cocaine is a potent vasoconstrictor and may result in a life-threatening reaction, even with the individual's first use of the drug. Arteriovenous malformations, trauma, and intracerebral aneurysm rupture are associated with hemorrhagic stroke.

A patient admitted with a stroke is coming to the unit from the emergency department. The nurse assigned to care for the new patient knows that what assessment finding is indicative of a stroke? a) Difficulty speaking b) Increase in heart rate c) Facial edema d) Electrolyte imbalance

a) Difficulty speaking - Difficulty speaking is a classic abnormal finding on a physical assessment that may be associated with a stroke. Tachycardia, edema, and electrolyte imbalances are not common initial presentations of stroke.

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? a) Ischemic b) Hemorrhagic c) Right-sided d) Left-sided

a) Ischemic - 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.

Which of the following antiseizure medication has been found to be effective for post-stroke pain? a) Lamotrigine (Lamictal) b) Phenytoin (Dilantin) c) Carbamazepine (Tegretol) d) Topiramate (Topamax)

a) Lamotrigine (Lamictal) - The antiseizure medication lamotrigine (Lamictal) has been found to be effective for post-stroke pain.

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? a) impaired cerebral circulation b) cardiac disease c) diabetes insipidus d) hypertension

a) impaired cerebral circulation - 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.

A client recently experienced a stroke with accompanying left-sided paralysis. His family voices concerns about how to best interact with him. They report the client doesn't seem aware of their presence when they approach him on his left side. What advice should the nurse give the family? a) "The client is feeling an emotional loss. He'll eventually start acknowledging you on his left side." b) "The client is unaware of his left side. You should approach him on the right side." c) "The client is unaware of his left side. You need to encourage him to interact from this side." d) "This condition is temporary."

b) "The client is unaware of his left side. You should approach him on the right side." - The client is experiencing unilateral neglect and is unaware of his left side. The nurse should advise the family to approach him on his unaffected (right) side. Approaching the client on the affected side would be counterproductive. It's too premature to make the determination whether this condition will be permanent.

Which term refers to the inability to perform previously learned purposeful motor acts on a voluntary basis? a) Agnosia b) Agraphia c) Perseveration d) Apraxia

d) Apraxia - Verbal apraxia refers to difficulty forming and organizing intelligible words although the musculature is intact. Agnosia is a failure to recognize familiar objects perceived by the senses. Agraphia refers to disturbances in writing intelligible words. Perseveration is the continued and automatic repetition of an activity or word or phrase that is no longer appropriate.

When communicating with a client who has sensory (receptive) aphasia, the nurse should: a) allow time for the client to respond. b) speak loudly and articulate clearly. c) give the client a writing pad. d) use short, simple sentences.

d) use short, simple sentences. - Although sensory aphasia allows the client to hear words, it impairs the ability to comprehend their meaning. The nurse should use short, simple sentences to promote comprehension. Allowing time for the client to respond might be helpful but is less important than simplifying the communication. Because the client's hearing isn't affected, speaking loudly isn't necessary. A writing pad is helpful for clients with expressive, not receptive, aphasia.

The nurse is caring for a client with aphasia. Which strategy will the nurse use to facilitate communication with the client? a) Speaking loudly b) Establishing eye contact c) Avoiding the use of hand gestures d) Speaking in complete sentences

b) Establishing eye contact - The following strategies should be used by the nurse to encourage communication with a client with aphasia: face the client and establish eye contact, speak in your usual manner and tone, use short phrases, and pause between phrases to allow the client time to understand what is being said; limit conversation to practical and concrete matters; use gestures, pictures, objects, and writing; and as the client uses and handles an object, say what the object is. It helps to match the words with the object or action. Be consistent in using the same words and gestures each time you give instructions or ask a question, and keep extraneous noises and sounds to a minimum. Too much background noise can distract the client or make it difficult to sort out the message being spoken.

A client is prescribed warfarin. Client teaching has included instructions to maintain a diet rich in foods that contain vitamin K. What sources of food should the nurse instruct the client to eat? a) Fish, meats, and vegetable oils b) Citrus fruits c) Milk and dairy products d) Cereals, soybeans, and spinach

d) Cereals, soybeans, and spinach - Clients who take warfarin (Coumadin) must be informed that they should eat foods rich in vitamin K. Examples of food sources of vitamin K include cabbage, cauliflower, spinach, and other green leafy vegetables, cereals, and soybeans. Other food groups are not known to contain vitamin K. Milk and dairy products are good sources of calcium, while citrus fruits are sources of vitamin C. Fish, meats, and oils are sources of proteins and fats.

A client tells the nurse that they have transient ischemic attacks. The client reports having undergone a carotid artery surgery. In such a case, what important assessments should be performed by the nurse? a) Sexual history b) Motor and sensory responses c) Blood pressure and weight d) Frequent neurologic checks

d) Frequent neurologic checks - If the client undergoes carotid artery surgery, the nurse performs frequent neurologic checks to detect paralysis, confusion, facial asymmetry, or aphasia. Body weight is measured because obesity, hyperlipidemia, and atherosclerosis are related to cerebrovascular disease, and not in the case of carotid artery surgery. Sexual history and motor and sensory responses are not important assessments to be performed for such clients.

A nurse is teaching about ischemic stroke prevention to a community group and emphasizes that control of hypertension, which is the major risk factor for stroke, is key to prevention. Ways to control hypertension include the Dietary Approaches to Stop Hypertension (DASH) diet. This diet includes which of the following? a) Moderate amounts of low-fat dairy products b) Moderate amounts of animal protein c) High amounts of low-fat dairy products d) Moderate amounts of fruits and vegetables

c) High amounts of low-fat dairy products - The DASH diet is high in fruits and vegetables, moderate in low-fat dairy products, and low in animal protein.

A nurse is assisting with a community screening for people at high risk for stroke. To which of the following clients would the nurse pay most attention? a) A 60-year-old Black man b) A 40-year-old White woman c) A 62-year-old White woman d) A 28-year-old pregnant Black woman

a) A 60-year-old Black man - The 60-year-old Black man has three risk factors: gender, age, and race. Black people have almost twice the incidence of first stroke compared with White people.

Which term refers to the failure to recognize familiar objects perceived by the senses? a) Agnosia b) Agraphia c) Apraxia d) Perseveration

a) Agnosia - Auditory agnosia is failure to recognize significance of sounds. Agraphia refers to disturbances in writing intelligible words. Apraxia refers to an inability to perform previously learned purposeful motor acts on a voluntary basis. Perseveration is the continued and automatic repetition of an activity, word, or phrase that is no longer appropriate.

An emergency department nurse is interviewing a client who is presenting with signs of an ischemic stroke that began 2 hours ago. The client reports a history of a cholecystectomy 6 weeks ago and is taking digoxin, warfarin, and labetalol. What factor poses a threat to the client for thrombolytic therapy? a) International normalized ratio greater than 2 b) Two hour time period of the stroke c) Taking digoxin d) Surgery 6 weeks ago

a) International normalized ratio greater than 2 - The client is at risk for further bleeding if the international normalized ratio is greater than 2. Thrombolytic therapy must be initiated within 3 hours in clients with ischemic stroke. The client is not eligible for thrombolytic therapy if she has had surgery within 14 days. Digoxin and labetalol do not prohibit thrombolytic therapy.

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? a) Transient ischemic attack (TIA) b) Left-sided cerebrovascular accident (CVA) c) Right-sided cerebrovascular accident (CVA) d) Completed Stroke

b) Left-sided cerebrovascular accident (CVA) - 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 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? a) Left-sided stroke b) Right-sided stroke c) Cerebral aneurysm d) Transient ischemic attack

d) Transient ischemic attack - 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.

A nurse is instructing the spouse of a client who suffered a stroke about the use of eating devices the client will be using. During the teaching, the spouse starts to cry and states, "One minute he is laughing, and the next he's crying; I just don't understand what's wrong with him." Which statement is the best response by the nurse? a) "Emotional lability is common after a stroke, and it usually improves with time." b) "You sound stressed; maybe using some stress management techniques will help." c) "You seem upset, and it may be hard for you to focus on the teaching, I'll come back later." d) "This behavior is common in clients with stroke. Which does your spouse do more often? Laugh or cry?"

a) "Emotional lability is common after a stroke, and it usually improves with time." - This is the most therapeutic and informative response. Often, most relatives of clients with stroke handle the physical changes better than the emotional aspects of care. The family should be prepared to expect occasional episodes of emotional lability. The client may laugh or cry easily and may be irritable and demanding or depressed and confused. The nurse can explain to the family that the client's laughter does not necessarily connote happiness, nor does crying reflect sadness, and that emotional lability usually improves with time. The remaining responses are nontherapeutic and do not address the spouse's concerns.

The nurse is taking care of a client with a headache. In addition to administering medications, the nurse takes which measure to assist the client in reducing the pain associated with the headache? a) Apply warm or cool cloths to the forehead or back of the neck. b) Maintain hydration by drinking eight glasses of fluid a day. c) Perform the Heimlich maneuver. d) Use pressure-relieving pads or a similar type of mattress.

a) Apply warm or cool cloths to the forehead or back of the neck. - Warmth promotes vasodilation; cool stimuli reduce blood flow.

Which interventions would be recommended for a client with dysphagia? Select all that apply. a) Assist the client with meals. b) Place food on the affected side of the mouth. c) Test the gag reflex before offering food or fluids. d) Allow ample time to eat.

a) Assist the client with meals. c) Test the gag reflex before offering food or fluids. d) Allow ample time to eat. - Interventions for dysphagia include placing food on the unaffected side of the mouth, allowing ample time to eat, assisting the client with meals, and testing the client's gag reflex before offering food or fluids.

Which of the following is the most common side effect of tissue plasminogen activator (tPA)? a) Bleeding b) Headache c) Increased intracranial pressure (ICP) d) Hypertension

a) Bleeding - Bleeding is the most common side effect of tPA. The patient is closely monitored for bleeding (at IV insertion sites, gums, urine/stools, and intracranially by assessing changes in level of consciousness). Headache, increased ICP, and hypertension are not side effects of tPA.

The nurse is caring for a client who has had a cerebrovascular accident. The client has a nursing diagnosis of altered nutritional status related to difficulty swallowing. What intervention would it be important for the nurse to institute? a) Encourage the client to eat semisolid foods and cold foods. b) Encourage the client to drink hot liquids. c) Encourage the client to eat tepid foods. d) Encourage the client to eat solid foods.

a) Encourage the client to eat semisolid foods and cold foods. - When the client can resume oral intake after a CVA, individualize the diet according to his or her ability to chew and swallow. Semisolid and medium-consistency foods such as pudding, scrambled eggs, cooked cereals, and thickened liquids are easiest to swallow. Cold foods stimulate swallowing. The client should avoid tepid foods, because they are more difficult to locate in the mouth, and extremely hot foods, which can cause overreaction. Therefore options B, C, and D are incorrect.

A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? a) Heparin sodium b) Dexamethasone c) Methyldopa d) Phenytoin

a) Heparin sodium - Administering heparin, an anticoagulant, could increase the bleeding associated with hemorrhagic stroke. Therefore, the nurse should question this order to prevent additional hemorrhage in the brain. In a client with hemorrhagic stroke, the healthcare provider may use dexamethasone (Decadron) to decrease cerebral edema and pressure, methyldopa (Aldomet) to reduce blood pressure, and phenytoin (Dilantin) to prevent seizures.

Which is a contraindication for the administration of tissue plasminogen activator (t-PA)? a) Intracranial hemorrhage b) Ischemic stroke c) Age 18 years or older d) Systolic blood pressure less than or equal to 185 mm Hg

a) Intracranial hemorrhage - 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.

The nurse is caring for a client following an aneurysm coiling procedure. The nurse documents that the client is experiencing Korsakoff syndrome. Which set of symptoms characterizes Korsakoff syndrome? a) Psychosis, disorientation, delirium, insomnia, and hallucinations b) Severe dementia and myoclonus c) Tremor, rigidity, and bradykinesia d) Choreiform movement and dementia

a) Psychosis, disorientation, delirium, insomnia, and hallucinations - Advances in technology have led to the introduction of interventional neuroradiology for the treatment of aneurysms. Endovascular techniques may be used in selected clients to occlude the blood flow from the artery that feeds the aneurysm with coils or other techniques to occlude the aneurysm itself. Postoperative complications are rare but can occur. Potential complications include psychological symptoms such as disorientation, amnesia, and Korsakoff syndrome (disorder characterized by psychosis, disorientation, delirium, insomnia, hallucinations, and personality changes). Creutzfeldt-Jakob disease results in severe dementia and myoclonus. The three cardinal signs of Parkinson disease are tremor, rigidity, and bradykinesia. Huntington disease results in progressive involuntary choreiform (dancelike) movements and dementia.

An emergency department nurse is awaiting the arrival of a client with signs of an ischemic stroke that began 1 hour ago, as reported by emergency medical personnel. The treatment window for thrombolytic therapy is which of the following? a) Three hours b) One hour c) Two hours d) Six hours

a) Three hours - Rapid diagnosis of stroke and initiation of thrombolytic therapy (within 3 hours) in clients with ischemic stroke leads to a decrease in the size of the stroke and an overall improvement in functional outcome after 3 months.

A client is experiencing severe pain related to increased ICP. Which analgesic would be ordered for this client to help alleviate pain? a) codeine b) hydrocodone c) morphine d) fentanyl

a) codeine - Avoid administering opioid analgesics, except codeine. Opioids interfere with accurate assessment of neurologic function because they constrict the pupils and depress LOC.

During a class on stroke, a junior nursing student asks what the clinical manifestations of stroke are. What would be the instructor's best answer? a) "Clinical manifestations of a stroke are highly variable, depending on the cardiovascular health of the client." b) "Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation." c) "Clinical manifestations of a stroke generally include aphasia, one-sided flaccidity, and trouble swallowing." d) "Clinical manifestations of a stroke depend on how quickly the clot can be dissolved."

b) "Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation."

A client undergoes cerebral angiography for evaluation of a subarachnoid hemorrhage. Which findings indicate spasm or occlusion of a cerebral vessel by a clot? a) Nausea, vomiting, and profuse sweating b) Hemiplegia, seizures, and decreased level of consciousness c) Difficulty breathing or swallowing d) Tachycardia, tachypnea, and hypotension

b) Hemiplegia, seizures, and decreased level of consciousness - 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.

A client is receiving an IV infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To confirm that this drug is producing its therapeutic effect, the nurse should consider which finding most significant? a) Decreased level of consciousness (LOC) b) Elevated blood pressure c) Increased urine output d) Decreased heart rate

c) Increased urine output - The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output. A decreased LOC and elevated blood pressure may indicate lack of therapeutic effectiveness. A decreased heart rate doesn't indicate that mannitol is effective.

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? a) 12-lead electrocardiogram b) Carotid ultrasound study c) Noncontrast computed tomogram d) Transcranial Doppler flow study

c) Noncontrast computed tomogram - 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).

A nurse is reading a journal article about stroke and the underlying causes associated with this condition. The nurse demonstrates understanding of the information when identifying which subtype of stroke as being due to atrial fibrillation? a) large-artery thrombotic b) small, penetrating artery thrombotic c) cardio embolic d) cryptogenic

c) cardio embolic - Ischemic strokes are further divided into five subtypes, according to a mechanism-based classification system: large-artery thrombotic strokes (representing 20% of ischemic strokes); small, penetrating artery thrombotic strokes (25%); cardio embolic strokes (20%); cryptogenic strokes (strokes that cannot be attributed to any specific cause) (30%); and "other" (5%). Large-artery thrombotic strokes are caused by atherosclerotic plaques in the large blood vessels of the brain. Thrombus formation and occlusion can occur at the site of the atherosclerosis and result in ischemia and infarction (tissue death). Small, penetrating artery thrombotic strokes that affect one or more vessels and cause reduced blood flow are the most common type of ischemic stroke, typically caused by longstanding hypertension, hyperlipidemia, or diabetes. Cardio embolic strokes are associated with cardiac dysrhythmias, such as atrial fibrillation, but can also be associated with valvular heart disease or left ventricular thrombus. The last two classifications of ischemic strokes are cryptogenic strokes, which have no identified cause, and strokes from other causes, such as illicit drug use (cocaine), coagulopathies, migraine, or spontaneous dissection of the carotid or vertebral arteries.

The nurse is caring for a client with a history of transient ischemic attacks (TIAs) and moderate carotid stenosis who has undergone a carotid endarterectomy. Which postoperative finding would cause the nurse the most concern? a) Neck pain rated 3 of 10 (on a 0 to 10 pain scale) b) Blood pressure 128/86 mm Hg c) Mild neck edema d) Difficulty swallowing

d) Difficulty swallowing - The client's inability to swallow without difficulty would cause the nurse the most concern. Difficulty swallowing, hoarseness, or other signs of cranial nerve dysfunction must be assessed. The nurse focuses on assessment of the following cranial nerves: facial (VII), vagus (X), spinal accessory (XI), and hypoglossal (XII). Some edema in the neck after surgery is expected; however, extensive edema and hematoma formation can obstruct the airway. Emergency airway supplies, including those needed for a tracheostomy, must be available. The client's neck pain and mildly elevated blood pressure need to be addressed but would not cause the nurse the most concern. Hypotension is avoided to prevent cerebral ischemia and thrombosis. Uncontrolled hypertension may precipitate cerebral hemorrhage, edema, hemorrhage at the surgical incision, or disruption of the arterial reconstruction.

When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke? a) The day before the patient is discharged b) After the patient has passed the acute phase of the stroke c) After the nurse has received the discharge orders d) The day the patient has the stroke

d) The day the patient has the stroke - Although rehabilitation begins on the day the patient has the stroke, the process is intensified during convalescence and requires a coordinated team effort.