Stroke

the nurse is planning information about stroke frequency as part of a community health education program. Which demographic groups should the nurse include that are at higher than average risk for stroke? (Select all that apply.) a.Pregnant women b.Asian Americans c.American Indians d.African Americans e.Men and women 75 years old or older f.Individuals who have had a transient ischemic attack (TIA)

.ANS:A, C, D, E, F Some population groups, such as African Americans, American Indians, Alaskan natives, and Mexican Americans, have a higher than average risk. Recent studies indicate that the risk of stroke may be higher in women during pregnancy and the 6 weeks following childbirth. Patients who have had a TIA have an increased risk of having a stroke; about 24% to 29% of patients who experience a TIA will have a stroke within 5 years. Strokes are most common in people over the age of 75. B. Asian Americans are not as high risk.

after a stroke, a client has ataxia. what intervention is most appropriate to include on the clients plan of care? a. ambulate only with a gait belt b. encourage double swallowing c. monitor long sounds after eating d. perform post void residuals

ANS: A Ataxia is a gait disturbance. For the clients safety, he or she should have assistance and use a gait belt when ambulating. Ataxia is not related to swallowing, aspiration, or voiding.

the nurse is reviewing teaching provided to a patient with transient ischemic attack (TIA). Which statement indicates that further teaching is required? a. the risk factors and symptoms of a tia are just like those of a stroke b. i need to stop smoking to help lower my chances of this happenning again c. my risk for alzheimers disease is increased now so ill have to stop driving d. i recognize how important it is to take my anti-hypertension medications regularly

ANS:C There is no association between TIA and the development of Alzheimers disease. A. The risk factors, causes, and symptoms of a TIA are identical to a cerebrovascular accident (CVA). Patients who have had a TIA have an increased risk of having a stroke. Treatment, therefore, is mostly focused on minimizing the patients risk factors for a stroke. B. D. Modifiable risk factors are those risks that can be changed by treatment, such as treating high blood pressure, or by lifestyle modification, such as stopping smoking.

The female patient has been brought to the ED with a sudden onset of a severe headache that is different from any other headache she has had previously. When considering the possibility of a stroke, which type of stroke should the nurse know is most likely occurring? A. TIA B. Embolic stroke C. Thrombotic stroke D. Subarachnoid hemorrhage

D. Subarachnoid hemorrhageHeadache is common in a patient who has a subarachnoid hemorrhage or an intracerebral hemorrhage. A TIA is a transient loss of neurologic function usually without a headache. A headache may occur with an ischemic embolic stroke, but severe neurologic deficits are the initial symptoms. The ischemic thrombotic stroke manifestations progress in the first 72 hours as infarction and cerebral edema increase.

The priority intervention in the emergency department for the patient with a stroke is a. intravenous fluid replacement b. administration of osmotic diuretics to reduce cerebral edema c. initiation of hypothermia to decrease the oxygen needs of the brain d. maintenance of respiratory function with a patent airway and oxygen administration

D: Maintenance of respiratory function with a patent airway and oxygen administration- the first priority in acute management of the patient with a stroke is preservation of life. Because the patient with a stroke may be unconscious or have a reduced gag reflex, it is most important to maintain a patent airway for the patient and provide oxygen if respiratory effort is impaired. IV fluid replacement, treatment with osmotic diuretics, and perhaps hypothermia may be used for further treatment.

A patient comes to the emergency department immediately after experiencing numbness of the face and an inability to speak, but while the patient awaits examination, the symptoms disappear and the patient request discharge. The nurse stresses that it is important for the patient to be evaluated primarily because a. the patient has probably experienced an asymptomatic lacunar stroke b. the symptoms are likely to return and progress to worsening neurologic deficit in the next 24 hours c. neurologic deficits that are transient occur most often as a result of small hemorrhages that clot off d. the patient has probably experienced a transient ischemic attack (TIA), which is a sign of progressive cerebral vascular disease

D: The patient has probably experienced a transient ischemic attack (TIA), which is a sign of progressive cerebral vascular disease- A TIA is a temporary focal loss of neurologic function caused by ischemia of an area of the brain, usually lasting only about 3 hours. TIAs may be due to microemboli from heart disease or carotid or cerebral thrombi and are a warning of progressive disease. Evaluation is necessary to determine the cause of the neurologic deficit and provide prophylactic treatment if possible.

for the client who is at risk for stroke, the most important guideline the nurse should teach is to a. increase drinks with caffeine b. monitor blood pressure c. increase amounts of sodium in the diet d. monitor weight and activity

b Monitoring weight and activity is important, but the highest priority is monitoring the blood pressure. This is a modifiable risk factor that, when controlled, will decrease the risk of stroke.

A patient is diagnosed with a stroke that occurred at 12 noon the previous day. When should the nurse plan to begin bedside physical therapy with this patient? a. after five days b. within 2 -3 days c. by 12 noon on the current day d. at least one week after the occurence

c Patients should be mobilized within 24 hours if possible to prevent complications of immobility. Physical and occupational therapy are provided to maximize functioning and to progress the patient toward a return to baseline functioning. A. B. D. Waiting to begin physical therapy could reduce the patients success with physical rehabilitation.

the nurse explains to the patient with a stroke who is scheduled for angiography that this test is used to determine the a. presence of increased ICP b. site and size of the infarction c. patency of the cerebral blood vessels d. presence of blood in the cerbrospinal fluid

c Rationale: Angiography provides visualization of cerebral blood vessels and can help estimate perfusion and detect filling defects in the cerebral arteries.

A patient experiencing TIAs is scheduled for a carotid endarterectomy. The nurse explains that this procedure is done to a. decrease cerebral edema. b. reduce the brain damage that occurs during a stroke in evolution. c. prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow. d. provide a circulatory bypass around thrombotic plaques obstructing cranial circulation.

c Rationale: In a carotid endarterectomy, the atheromatous lesion is removed from the carotid artery to improve blood flow.

A patient is experiencing bilateral hemiparesis, dysphasia, visual changes, and altered level of consciousness, ataxia, and dysphagia. Which artery was most likely affected in this patients stroke? a. carotid b. middle cerebral c. posterior cerebral d. vertebrobasilar/cerebellar

d These are symptoms of vertebrobasilar/cerebellar occlusion. A. B. C. Carotid and middle or posterior cerebral occlusions are not associated with ataxia or dysphagia.

A patient has been prescribed pravastatin (Pravachol) to reduce cholesterol level after having a transient ischemic attack (TIA). What possible side effect should the nurse include when teaching the patient about this drug? a. diarrhea b. purple toe c. confusion d. muscle aches

d Muscle pain or aches can signal a serious side effect (rhabdomyolysis) and should be reported. A. B. C. Diarrhea, purple toe, and confusion are not side effects of statins.

The patient is diagnosed with a cerebral vascular accident that has the slowest rate of recovery and the highest probability of causing extensive neurological deficits. For which type of stroke should the nurse plan care for this patient? a. thrombotic stroke b. cerebral aneurysm c. subarachnoid hemorrhage d. reversible ischemic neurological deficit

.ANS:C SAH is caused by rupture of blood vessels on the surface of the brain. This type of infarct has the slowest rate of recovery and the highest probability of leaving the patient with extensive neurological deficits. B. Aneurysms are often asymptomatic if they do not bleed. D. RIND is reversible. A. A thrombotic stroke does not have the slowest rate of recovery.

A patient is prescribed an antiplatelet agent to prevent strokes. Which agent was this patient most likely prescribed? a. aspirin b. warfarin c. tylenol d. tPA

A Aspirin is a platelet aggregation inhibitor. C. Tylenol is an analgesic but does not affect platelet function. B. Warfarin is an anticoagulant. D. tPA is a thrombolytic agent.

The nurse is caring for a patient who recently suffered a cerebrovascular accident(CVA). Family members ask the nurse why their father had a seizure. Which response is best forthe nurse to make? a. "The seizure was most likely caused by brain cells being deprived of oxygen due to a blood clot in the brain." b. "The stroke generated a toxin that excites the brain cells." c. "The stroke causes an alteration in the cells adjacent to the blood clot." d. "The stroke causes an increase in the depolarization of the brain cells due to the clot formation."

A Thrombi from a CVA can occlude vessels, cutting off oxygen supply to cells of the brain and causing aseizure.

the nurse is assisting with teaching a patient who has had a transient ischemic attack (TIA). On which understanding should the nurse base teaching? a. tias are not serious, and the patient should have no further problems b. a tia is predictive that the patient will have a heart attack with in 1 year c. a tia is a medical emergency that requires immediate surgical intervention d. a tia is a forewarning that the patient is at risk for a cerbrovascular accident

ANS d About a third of patients who experience a TIA will have a stroke in the future. A. Urgent evaluation of TIA is essential in order to decrease the risk of stroke. B. There are no data related to myocardial infarction (MI) prediction. C. It is not a surgical problem.

the results of a carotid Doppler study indicate that a patient has stenosis of the left carotid artery. For which diagnostic test should the nurse prepare the patient to have completed next? a.MRI b.CT scan c.Echocardiogram d.Carotid angiography

ANS d Carotid Doppler testing uses ultrasound to detect stenosis of the carotid arteries. Carotid angiography can be done to further determine degree of blockage and help guide treatment. A. B. C. After a carotid Doppler, an MRI, CT scan, or echocardiogram are not indicated.

Which patient being cared for in the emergency department should the charge nurse evaluate first? a a patient with a complete spinal injury at c5 dermatome level b. a patient with a glasgow coma scale score of 15 on 3 L nasal cannula c. an alert patient with a subdural bleed who is complaining of a headache d. an ischemic stroke patient with a blood pressure of 190/100 mmHg

ANS: A A patient with a C5 complete spinal injury is at risk for ineffective breathing patterns and should be assessed immediately for any airway compromise. A GCS score of 15 indicates a neurologically intact patient. The patient with a subdural bleed is alert and not in danger of any immediate compromise. The goal for ischemic stroke is to keep the systolic BP less than 220 mm Hg and the diastolic blood pressure less than 120 mm Hg.

The nurse working in the emergency department assesses a client who has symptoms of stroke. For what modifiable risk factors should the nurse assess? (Select all that apply.) a. Alcohol intake b. Diabetes c. High-fat diet d. Obesity e. Smoking

ANS: A, C, D, E Alcohol intake, a high-fat diet, obesity, and smoking are all modifiable risk factors for stroke. Diabetes is not modifiable but is a risk factor that can be controlled with medical intervention.

A nurse has applied to work at a hospital that has National Stroke Center designation. The nurse realizes the hospital adheres to eight Core Measures for ischemic stroke care. What do these Core Measures include? (Select all that apply.) a. Discharging the client on a statin medication b. Providing the client with comprehensive therapies c. Meeting goals for nutrition within 1 week d. Providing and charting stroke education e. Preventing venous thromboembolism

ANS: A, D, ECore Measures established by The Joint Commission include discharging stroke clients on statins, providing and recording stroke education, and taking measures to prevent venous thromboembolism. The client must be assessed for therapies but may go elsewhere for them. Nutrition goals are not part of the Core Measures.

The nurse admits a patient to the emergency department with new onset of slurred speech and right-sided weakness. What is the priority nursing action? a. assess for the presence of a headache b. assess the patients general orientation c. determine the patients drug allergeis d. determine the time of symptom onset

ANS: D Early intervention for ischemic stroke is recommended. Thrombolytics must be given within 3 hours of the onset of symptoms. Although assessment of allergies, as well accompanying symptoms such as a headache and general orientation, are a part of a complete neurological assessment and should be performed, time of onset of symptoms is critical to the type of treatment.

when teaching about clopidogrel (Plavix) the nures will tell the patient with cerebral atherosclerosis a. to monitor and record the blood pressure daily b. that plavix will dissolve clots in the cerebral arteries c. that plavix will reduce cerebral artery plaque formation d. to call the health care provider if stools are bloody or tarry

ANS: D Clopidogrel (Plavix) inhibits platelet function and increases the risk for gastrointestinal bleeding, so patients should be advised to notify the health care provider about any signs of bleeding. The medication does not lower blood pressure, decrease plaque formation, or dissolve clots.

a client is being evaluated for a stroke. the nurse knows that one of the easiest and most common diagnoistic tests used to differentiate between strokes is a. CT skan b. MRI c. EEG d. PET Scan

ANS: a The CT scan is widely available in most hospitals and is an important tool to differentiate between ischemic strokes and hemorrhagic stroke. It is the most common tool used to diagnose a stroke. An MRI is contraindicated in clients with metal implants or pacemakers, and it can exacerbate claustrophobia. An EEG will determine the presence of brain waves, and it is not a diagnostic test for a stroke. A PET scan determines brain tissue functioning but, it will not be able to differentiate between the types of strokes.

A client diagnosed with an embolic stroke is not a candidate for tPA. The nurse realizes that the client might be eligible for which of the following forms of treatment? a. carotid stenting b. antiarrhythmic medication c. intravenous fluid therapy d. carotid endarterectomy

ANS: a In clients who are ineligible for tPA therapy, catheter-based treatment such as stenting may be an option. Carotid endarterectomy is used to prevent a stroke. Antiarrhythmic medication does not prevent a stroke. Intravenous fluid therapy does not prevent a stroke.

A client is being seen in the emergency department experiencing symptoms of a stroke. The nurse realizes that the administration of a medication to break clots, such as tPA, should be administered within how many minutes of the client presenting to the emergency department? a. 30 minutes b. 60 minutes c. 90 minutes d. 120 minutes

ANS: b Medications like tPA should be given within 60 minutes of the clients arrival to the emergency department. This is why health care teams must have a plan to deal with stroke clients quickly and efficiently.

. A patient with symptoms of impending stroke is scheduled to have a cerebral angiogram. Which statement should the nurse include when assisting with patient teaching? a. this test is designed to detect vascular lesions in the brain b. the angiogram is done to help identify swelling in the brain c. we need to do this to evaluate electrical function of the brain d. this test is done to examine cerebrospinal fluid for signs of bleeding

ANS:A A cerebral angiogram may be completed to determine the patency of cerebral vessels and the status of any collateral circulation. D. A lumbar puncture is done to examine cerebrospinal fluid (CSF). B. Edema may be identified by radiography. C. An electroencephalogram (EEG) shows electrical function.

A patient began experiencing manifestations of a stroke at 0800 hours. By which time should thrombolytic medications be provided to reverse stroke symptoms? a. 0900 hours b. 1250 hours c. 1400 hours d. 1660 hours

ANS:B If a patient experiencing ischemic stroke symptoms receives treatment within 4.5 hours of symptom onset, medication can be provided to resolve the deficits. A. A patient needs to be treated within 4.5 hours and not 1 hour. C. D. This is too long to wait to provide medication to treat the symptoms of a stroke.

A patient tells the nurse that at times it seems like the mouth muscles do not want to work and the patients speech is slurred. What should the nurse realize that the patient is describing? a. diplopia b. dysarthria c. dysphagia d. dysrhythmia

ANS:B Slurred or indistinct speech because of a motor problem or lack of coordination is referred to as dysarthria. A. Diplopia is double vision. C. Dysphasia refers to difficulty swallowing. D. Dysrhythmia is an irregular heartbeat.

A patient with a temporary loss of motor function is diagnosed with a transient ischemic attack (TIA). What should the nurse include when assisting in the teaching about this health problem? a. you had a small hemorrhage in your brain b. your brain was temporarily deprived of oxygen c. the neurons in your brain are tangled so messages get mixed up d. you have a vessel that is occluded, blocking the blood supply to your brain

ANS:B TIA is a temporary impairment of the cerebral circulation causing neurological impairment that lasts less than 24 hours. A. A hemorrhage would cause a hemorrhagic stroke. D. A fully occluded vessel causes an ischemic stroke. C. Tangled messages refer to Alzheimers disease.

The nurse is providing care for a patient with expressive aphasia. What should the nurse expect to find in the patients plan of care? (Select all that apply.) a.Speak loudly. b.Use a picture board. c.Obtain an interpreter. d.Provide pencil and paper. e.Speak slowly and clearly. f.Gesture or pantomime the message.

ANS:B, D For expressive aphasia, pencil and paper or a picture board can help with communication. A. Speaking loudly is not helpful unless the patient has a hearing deficit also. E. F. Speaking slowly and pantomiming may be helpful for receptive aphasia, not expressive. C. Interpreters are used for language barriers, not for aphasia.

The nurse is documenting care provided to a patient with left-sided flaccidity caused by a stroke. Which term should the nurse use to document this patients motor status? a. ipsilateral paraplegia b. ipsilateral hemiparesis c. contralateral hemiplegia d. contralateral quadriparesis

ANS:C A patient with a stroke has symptoms on the opposite side of the stroke, which is called contralateral. One-sided flaccidity is called hemiplegia. A. Ipsilateral means the same side. Para refers to the lower extremities. D. Quad refers to all four extremities; B. Hemiparesis is another term for hemiplegia.

A patient enters the emergency department with right-sided weakness and vision changes. What assessment finding should be communicated to the registered nurse (RN) or HCP immediately? a. blood glucose 150 mg/dl b. blood pressure 148/92 mmHg c. onset of symptoms occured 90 minutes ago d. history of transient ischemic attack (TIA) 3 months ago

ANS:C All the data are significant. However, the onset of symptoms is within the time frame for the patient to receive a thrombolytic. If the nurse acts quickly, the patients stroke may be able to be reversed.

A patient with a cerebrovascular accident (stroke) has left-sided flaccidity and is unable to speak but seems to understand everything the nurse says. Which term should the nurse use to document the patients communication impairment? a. sensory aphasia b. motor dysphagia c. expressive aphasia d. receptive dysphagia

ANS:C Aphasia may be expressive, in which the patient knows what he or she wants to say but cannot speak or make sense. D. Receptive aphasia is an inability to understand spoken or written words. The patient experiencing receptive aphasia is unable to understand language. B. Dysphagia refers to difficulty swallowing. A. Sensory aphasia is not a type of communication impairment.

The nurse is planning care for a client with right-sided weakness and aphasia from a transient ischemic attack (TIA). Which area of the brain should the nurse realize was affected in this client? a. medulla b. occipital lobe c. left hemisphere d. right hemisphere

ANS:C Symptom onset is sudden and generally involves one side of the bodythe side of the body opposite to the damaged area. A. B. The manifestations of right-sided weakness and aphasia would not be present if the TIA occurred in the medulla or occipital lobe. D. The client would have left-sided manifestations if the TIA occurred in the right hemisphere.

the nurse would expect to find what clinical manifestation in a pt admitted with a left sided stroke? a. impulsivity b. impaired speech c. left side neglect d. short attention span

B. Impaired speech Clinical manifestations of left-sided brain damage include right hemiplegia, impaired speech/language, impaired right/left discrimination, and slow and cautious performance. Impulsivity, left-sided neglect, and short attention span are all manifestations of right-sided brain damage.

The nurse is assisting in preparing a patient for transfer to a rehabilitation facility after a stroke. What should the nurse explain as the goal for rehabilitation? a. to monitor neurological status b. to cure any effects of the stroke c. to maximize remaining abilities d. to determine the extent of neurological deficits

C Rehabilitation can help the patient maximize remaining abilities. A. D. At this point, the patients neurological status should be stable, and all the diagnostic work has been completed. B. Cure is not realistic.

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

C. Aspirin is ordered to prevent stroke in patients who have experienced TIAs. Documentation of the patient's refusal to take the medication is an inadequate response by the nurse. There is no need to clarify the order with the health care provider. The aspirin is not ordered to prevent aches and pains.

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

C. During the acute period, the nurse should place objects on the patient's unaffected side. Because there is a visual defect in the right half of each eye, an eye patch is not appropriate. The patient should be approached from the left side. The visual deficit may not resolve, although the patient can learn to compensate for the defect.

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

C. Hypertension is the single most important modifiable risk factor. People who drink more than 1 (for women) or 2 (for men) alcoholic beverages a day may increase risk for hypertension. Physical inactivity and obesity contribute to stroke risk but not as much as hypertension

Which sensory-perceptual deficit is associated with left-sided stroke (right hemiplegia)? 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. Slow and possibly fearful performance of tasks.Patients with a left-sided stroke (right hemiplegia) commonly are slower in organization and performance of tasks and may have a fearful, anxious response to a stroke. Overconfidence, spatial disorientation, and impulsivity are more commonly associated with a right-sided stroke.

The nurse is teaching a senior citizen's group about signs and symptoms of a stroke. Which statement by the nurse would provide accurate information? A. "Take the person to the hospital if a headache lasts for more than 24 hours." B. "Stroke symptoms usually start when the person is awake and physically active." C. "A person with a transient ischemic attack has mild symptoms that will go away." D. "Call 911 immediately if a person develops slurred speech or difficulty speaking."

D. "Call 911 immediately if a person develops slurred speech or difficulty speaking."Medical assistance should be obtained immediately for someone with signs and symptoms of a stroke such as sudden numbness; weakness; paralysis of the face, arm, or leg (especially on one side of the body); sudden confusion; trouble speaking or understanding; slurred speech; sudden trouble seeing in one or both eyes; sudden trouble walking; dizziness; loss of balance or coordination; or a sudden, severe headache with no known cause. A person with signs and symptoms of a transient ischemic attack should seek medical attention immediately because it is unknown if the symptoms will resolve or persist and progress to a stroke. Onset of signs and symptoms of a stroke vary depending on the type. Onset of an ischemic thrombotic stroke usually occurs at rest. Onset of an ischemic embolic stroke is not related to rest or activity, and onset of a hemorrhagic stroke usually occurs with activity.

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

D. Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 4.5 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the less brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.

a 73 year old patient with a stroke experiences facial drooping on the right side and right sided arm and leg paralysis. when admitting the patient, which clinical manifestation will the nurse expect to find a. impulsive behavior b. right sided neglect c. hyperactive left sided tendon reflexes d. difficulty comprehending instruction

D. Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with comprehension and use of language. The left-side reflexes are likely to be intact. Impulsive behavior and neglect are more likely with a right-side stroke.

the family of a client diagnosed with a stroke asks the nurse if this health problem is very common. The nurse should respond that in the United States a person has a stroke every: a. 40 seconds b. 1 minute c. 2 minutes d. 5 minutes

a In the United States, a person has a stroke every 40 seconds, and 700,000 new or recurrent strokes each year. Strokes are the third leading cause of death in the United States behind heart disease and cancer and are the leading cause of long-term disability.

Four days following a stroke, a patient is to start oral fluids and feedings. Before feeding the patient, the nurse should first a. check the patient's gag reflex b. order a soft diet for the patient c. raise the head of the bed to sitting position d. evaluate the patient's ability to swallow small sips of ice water

a check the patient's gag reflex- the first step in providing oral feedings for a patient with a stroke is ensuring that the patient has an intact gag reflex because oral feedings will not be provided if gag reflex is impaired. The nurse should then evaluate the patient's ability to swallow ice chips or ice water after placing the patient in an upright position

Which modifiable risk factors 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 hypertension is the single most important modifiable risk factor.

a client being tested for a stroke is not a candidate for tPA. which of the following would be contraindicated for the use of tPA (SATA a. minor ischemic stroke with in 30 days b. glucose level 120 mg/dl c. blood pressure 190/120 mmHg d. lumbar puncture 2 days ago e. stroke onset 5 hours ago f. INR 1.0

a c d e Contraindications of tPA to treat an embolic stroke include minor ischemic stroke within the last 30 days, blood pressure greater an 185 mmHg systolic or greater than 110 mmHg diastolic, lumbar puncture within the last 3 days, and onset of stroke greater than 3 hours. Glucose level of 120 mg/dL and INR of 1.0 would not be contraindications for tPA therapy.

The nurse is assisting with a community education program about stroke prevention. Which are non-modifiable risk factors for stroke that the nurse should include? (Select all that apply.) a.Gender b.Obesity c.Diabetes d.Heredity e.Smoking f.Elevated blood lipids

a d Gender and heredity are not modifiable. B. C. E. F. The patient can control diabetes, heart disease, diet, exercise, lipids, and smoking to some degree.

while instructing a client on stroke prevention, the nurse mentions medications that are useful in stroke prevention. The following medications are effective in preventing a stroke, EXCEPT: a. anticoagulants b. antiplatelets c. anticholinergics d. neuroprotective agents

c although anticholinergic drugs have a variety of uses, stroke prevention is not one of them. all the other medications are used in a variety of ways to help with stroke prevention

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

c the initial nursing action should be to assess airway and take any needed actions to esnure a patent airway

a patient with right hemisphere stroke has a nursing diagnosis of unilateral neglect related to sensory perceptual defecits. during the pt rehabiltation it is important for the nurse to a. avoid positioning the pt on the affected side b. place all objects for care on the patients unaffected side c. teach the patient to care consciously for the affected side d. protect the affected side from injury with pillows and supports

c teach the pt to care consciously for the affected side-unilateral neglect, or neglect syndrome, occurs when the pt with a stroke is unaware of the affected side of the body, putting it at risk for injury

The nurse suspects that a patient has vision changes caused by a stroke. What did the nurse assess to make this determination? a.Patient asks that all items be placed on the right side of the bed. b.Patient turns head away when blood is being drawn from an arm. c.Patient looks down at the floor when sitting on the side of the bed. d.Patient does not follow with the eyes as the nurse walks around the room.

d If the patients eyes do not follow the nurse when moving around the room, there is a good chance that the patient has a deficit in that visual field. A. B. C. Placing items on the right side of the bed, turning the ahead away while blood is being drawn, and looking down at the floor when sitting on the side of the bed do not indicate vision changes caused by a stroke.

A patient comes into the emergency department with symptoms of a stroke. Which medication should the nurse expect may be given to the patient if diagnostic testing confirms an ischemic stroke? a. heparin b. clopidogrel (plavix c. warfarin (coumadin) d. tPA

d tPA is a thrombolytic agent that can break down the thrombus causing the occlusion, which can potentially prevent or completely reverse the symptoms of an ischemic stroke. A. B. C. Heparin, warfarin, and clopidogrel can help prevent clots but are not effective in breaking up an existing clot.