05 2900 Stroke & ICP

Why do patients with increased ICP experience headaches and nausea?

Pressures in arteries, veins, cranial nerves.

True or false. The difference between receptive aphasia and expressive aphasia is that in receptive aphasia, the patient cannot understand what you're saying to them, while in expressive aphasia, the patient can receive information, but cannot express themselves.

TRUE!

True or false. Cushing's Triad is a sign of impending death.

TRUE! It is a medical emergency and can lead to death d/t brainstem compression!

What happens to the risk of stroke as we age?

The risk doubles with each decade after 55!

When managing pain in patients with increased ICP who has a temperature of 101.2, the nurse cools the patient with ice packs. What does the nurse need to avoid? Why? How would you fix it?

Making the patient shiver Why? It increases metabolism & workload of the brain. How would you fix? Give a sedative

True or false. If a patient with increased ICP has a temperature of 100.4 degrees, you can give them acetaminophen and provide cooling blankets.

True!

A patient with increased ICP complains of pain 6 out of 10. When administering meds, what do we not want to do?

We want to treat the pain, but NOT over sedate.

What is the antidote for heparin? A. vitamin K+ B. protamine sulfate C. heparin D. calcium

B. protamine sulfate

In which patient would a carotid endartectomy be contraindicated? SELECT ALL THAT APPLY. A. ischemic stroke B. subarachnoid stroke C. thrombotic stroke D. embolic stroke E. intracerebral stroke

B. subarachnoid stroke E. intracerebral stroke

In which patient would a mechanical embolus removal in cerebral ischemia (MERCI) be contraindicated? SELECT ALL THAT APPLY. A. ischemic stroke B. subarachnoid stroke C. thrombotic stroke D. embolic stroke E. intracerebral stroke

B. subarachnoid stroke E. intracerebral stroke

The purpose of a CT angiography is to: A. rapidly distinguish an ischemic stroke from a hemorrhagic stroke B. visualize the blood vessels to see if there's a filling defect C. improve patency of an artery D. disintegrate clot & reopen blood flow

B. visualize the blood vessels to see if there's a filling defect

A diagnosis of a ruptured cerebral aneurysm has been made in a patient with manifestations of a stroke. The nurse anticipates that treatment options that would be evaluated for the patient include: A. hyperventilation therapy B. surgical clipping of the aneurysm C. administration of hyperosmotic agents D. administration of thrombolytic therapy

B: Surgical clipping of they aneurysm Surgical management with clipping of an aneurysm to decrease re bleeding and vasospasm is an option for a stroke cause by rupture of a cerebral aneurysm. Placement of coils into the lumens of the aneurysm by intercentional radiologists is increasing in popularity. Hyperventilation therapy would increase vasodilation and the potential for hemorrhage. Thrombolytic therapy would be absolutely contraindicated, and if a vessel is patent, osmotic diuretics may leak into tissue, pulling fluid out of the vessel and increasing edema.

Choose the BEST answer. Anything that causes _____ can cause ICP. A. infection B. edema C. uremia D. hemorrhage E. inflammation

BEST answer is E. inflammation because it includes all of the other answers. - head injury - hydrocephalus - meningitis - hemorrhage - cerebral infarction - stroke - tumor - infection - TBI - meatoma - lead or arsenic intoxication - hepatic encephalopathy - cirrhosis - uremia... the list goes on!

What medications are used in stroke prevention for patients with a history of TIA? A. anti-coagulants B. anti-platelets C. beta blockers D. digoxin

B. anti-platelet drugs

What are we doing about nutrition in patients with ICP who is in a coma?

- Nutritional needs must be met regardless of state of consciousness - Nutrition replacement within 3 days - Full nutritional replacement within 7 days

Under normal circumstances, the skull maintains homeostasis of what 3 components?

1. Brain tissue 2. Blood 3. Cerebrospinal fluid

Why are we worried about stage 4 brain injury? What is occurring?

1. ICP rises to lethal levels 2. Herniation - brain tissue shifts to areas of less pressure 3. Death!

The brain needs a constant supply of what 2 things?

1. O2 2. glucose

What 2 ways does mannitol decrease ICP?

1. Plasma expansion --> DECREASES Hct & DECREASES blood viscosity in order to INCREASE CBF & O2 delivery = INCREASED PERFUSION 2. OSMOTIC - prevents reabsorption of Na+ & water so that fluid moves from tissues to blood vessels to DECREASE total brain fluid content

How is a-fib and stroke connected?

A weakened blood vessel may rupture in or near the brain, or diseased arteries may become blocked by a clot or plaque buildup. A-fib occurs because the heart is beating rapidly to compensate and allows blood to pool in the heart. That's when stroke risk increases because it causes clots to form and travel to the brain.

Which actions by the nurse illustrates a knowledge deficit in the eating/feeding care in a stroke patient with possible dysphagia? A. Addresses nutrition within 5 days of post stroke B. Does not administer fluids, pills, or food until evaluated by a speech therapist C. Before feeding, assesses gag reflex using a tongue blade D. HOB up E. Allows adequate time for patient to eat, and monitors for pocketing of food F. Uses a sippy cup for any approved liquids G. Gives fork on unaffected side and encourages chewing on unaffected side H. Approaches the patient from the unaffected side.

A. Addresses nutrition within 5 days of post stroke --> FALSE! Nutrition must be addressed within 72 hours (3 days) post stroke --> recovery and healing NEED NUTRIENTS!

The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? A. An oral anticoagulant medication. B. A thrombolytic medication. C. An anti-hyperuricemic medication. D. A beta-blocker medication.

A. An oral anticoagulant medication.

A patient has ICP monitoring with an intraventricular catheter. A priority nursing intervention for the patient is A. aseptic technique to prevent infection B. constant monitoring of ICP waveforms C. removal of CSF to maintain normal ICP D. sampling CSF to determine abnormalities

A. Aseptic technique to prevent infection- An intraventricular catheter is a fluid coupled system that can provide direct access for microorganisms to enter the ventricles of the brain, and aseptic technique is a very high nursing priority to decrease the risk for infection. Constant monitoring of ICP waveforms is not usually necessary, and removal of CSF for sampling or to maintain normal ICP is done only when specifically ordered

During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to control the client's: A. Blood pressure B. Respirations C. Temperature D. Pulse

A. Blood pressure

Which of the following tests would the nurse suspect a doctor would order in a patient who is experiencing increased ICP? SELECT ALL THAT APPLY: A. CT scan B. EEG C. MRI D. Cerebral angiography E. Troponin

A. CT scan B. EEG C. MRI D. Cerebral angiography

A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? A. Urine output increases B. Pupils are 8 mm and nonreactive C. Systolic BP remains at 150 mm Hg D. BUN and creatinine levels return to normal

A. Mannitol promotes osmotic diuresis by increasing the pressure gradient in the renal tubes. Fixed and dilated pupils are symptoms of increased ICP or cranial nerve damage. No information is given about abnormal BUN and creatinine levels or that mannitol is being given for renal dysfunction or blood pressure maintenance.

The nurse and unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? A. The assistant places her hand under the client's right axilla to help him/her move up in bed. B. The assistant places the client on the back with the client's head to the side. C. The assistant places a gait belt around the client's waist prior to ambulating. D. The assistant praises the client for attempting to perform ADL's independently.

A. The assistant places her hand under the client's right axilla to help him/her move up in bed. Why? The patient has right-sided paralysis.

The nurse is monitoring a patient for increased ICP following a head injury. Which of the following manifestations indicate an increased ICP (select all that apply) A. fever B. oriented to name only C. narrowing pulse pressure D. dilated right pupil > left pupil E. decorticate posturing to painful stimulus

A. fever B. oriented to name only D. dilated right pupil > left pupil E. decorticate posturing to painful stimulus A, B, D, E- The first sign of increased ICP is a change in LOC. Other manifestations are dilated ipsilateral pupil, changes in motor response such as posturing, and fever, which may indicate pressure on the hypothalamus. Changes in vital signs would be an increased systolic BP with widened pulse pressure and bradycardia

What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? A. Pupil size and papillary response B. Bowel sounds C. Echocardiogram D. Cholesterol level

A. pupil size and papillary response

A client who had a craniotomy 2 days earlier is receiving mannitol intravenously to decrease ICP. Which diagnostic lab value should be monitored while the client is receiving the medication? A. Serum osmolarity B. WBC count C. Serum cholesterol D. Electrolytes & fluids E. Erythrocyte sedimentation rate (ESR)

A. serum osmolarity Why? Mannitol is an osmotic diuretic and increases the serum osmolarity and pulls fluid from the tissues, decreasing cerebral edema. Serum osmolarity levels are assessed as a parameter to determine proper dosage.

What is the antidote for warfarin (coumadin)? A. vitamin K+ B. protamine sulfate C. heparin D. calcium

A. vitamin K+

A patient is admitted to the hospital with a left hemiplegia. To determine the size and location and to ascertain whether a stroke is ischemic or hemorrhagic, the nurse anticipates that the health care provider will request a A. CT scan B. lumbar puncture C. cerebral arteriogram D. positron emission tomography (PET)

A: CT scan A CT scan is the most commonly used diagnostic test to determine the size and location of the lesion and to differentiate a thrombotic stroke from a hemorrhagic stroke. Positron emission tomography (PET) will show the metabolic activity of the brain and provide a depiction of the extent of tissue damage after a stroke. Lumbar punctures are not performed routinely because of the chance of increased intracranial pressure causing herniation. Cerebral arteriograms are invasive and may dislodge an embolism or cause further hemorrhage; they are performed only when no other test can provide the needed information.

During the acute phase of a stroke, the nurse assesses the patient's vital signs and neurologic status every 4 hours. A cardiovascular sign that the nurse would see as the body attempts to increase cerebral blood flow is A. hypertension B. fluid overload C. cardiac dysrhythmias D. S3 and S4 heart sounds

A: Hypertension SNS!!! The body responds to the vasopasm and a decreased circulation to the brain that occurs with a stroke by increasing the BP, frequently resulting in hypertension. The other options are important cardiovascular factors to assess, but they do not result from impaired cerebral blood flow.

A newly admitted patient who has suffered a right sided brain stroke has a nursing diagnosis of disturbed visual sensory perception related to homonymous hemianopsia. Early in the care of the patient, the nurse should A. place objects on the right side within the patient's field of vision B. approach the patient from the left side to encourage the patient to turn the head C. place objects on the patient's left side to assess the patient's ability to compensate D. patch the affected eye to encourage the patient to turn the head to scan the environment

A: Place objects on the right side within the patient's field of vision The presence of homonymous hemianopia in a patient with right-hemisphere brain damage causes a loss of vision in the left field. Early in the care of the patient, objects should be placed on the right side of the patient in the field of vision, and the nurse should approach the patient from the right side. Later in treatment, patients should be taught to turn the head and scan the environment and should be approached from the affected side to encourage head turning. Eye patches are used if patients have diplopia (double vision).

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

A nurse of excellence knows that in stage 2 brain injury: A. compliance increases, volume increases and there is no change in ICP B. compliance decreases and volume and ICP increases C. ICP increases and you observe widening pulse pressure, bradycardia, decreased pulse, and decorticate posturing. D. the brain is adapting to the injury

B. compliance decreases, and volume and ICP increases

The nurse plans care for a patient with increased ICP with the knowledge that the best way to position the patient is to: A. keep the head of the bed flat B. elevate the head of the bed to 30 degrees C. maintain patient on the left side with the head supported on a pillow D. use a continuous rotation bed to continuously change patient position

B. elevate the head of the bed to 30 degrees

A client seeks medical attention at an ER after experiencing right-sided weakness and slurred speech. The client receives a diagnosis of ischemic stroke and is evaluated for treatment with thrombolytic therapy. A definite contraindication for thrombolytic therapy is: A. a normal CT scan of the brain B. a serious head injury 4 weeks earlier C. a hx of DM D. onset of neurological deficits 2 hours earlier

B. a serious head injury 4 weeks earlier Why? Contraindications to thrombolytic therapy for a client with ischemic stroke include a serious head injury within the previous 3 months, This would put the patient at risk of developing serious bleeding problems (specifically hemorrhage). A negative CT scan and onset of neurological deficits within 3 hours are indications of administering thrombolytic therapy. History of DM is not a contraindication.

A nurse is providing a teaching to a patient's spouse about the possibility of thrombolytic therapy for her husband who is is experiencing s/s of a stroke. Which of the following indicates a knowledge deficit by the nurse? SELECT ALL THAT APPLY. A. "The goal of thrombolytic therapy is to lyse & disintegrate the clot and reopen the blood flow." B. "In this procedure, the vessel is opened, the occlusion is manually cleaned out, and the vessel is sewn back up." C. "We must first wait for the results of the CT scan or MRI to verify if it is an ischemic stroke or hemorrhagic stroke. tPA can only be used in ischemic stroke patients." D. "tPA must be started within the first 4 hours, ideally within the first 1 hour." E. "It will be important to monitor the patient's vital signs, neuro status, and BP post therapy."

B. "In this procedure, the vessel is opened, the occlusion is manually cleaned out, and the vessel is sewn back up." --> FALSE! this is carotid endartectomy. D. "tPA must be started within the first 4 hours, ideally within the first 1 hour." --> FALSE! tPA needs to be administered within the first 3 hours, ideally within the first 1 hour.

A nurse is providing instruction to a patient regarding TIA. What should the nurse include in her teaching? A. "TIA is a neurological dysfunction that manifests as an acute infarction." B. "TIA causes ischemia." C. "Symptoms of TIA last less than 3 hours" D. "When the symptoms of TIA subside, a patient can be immediately discharged." E. "A patient who has a TIA does not have an increased risk of having a stroke." F. "Oftentimes, a patient with TIA is given nitroglycerin to help with the pain."

B. "TIA causes ischemia."

The lowest score you can get on a Glasgow coma scale is _(1)_ and the highest score you can get is _(2)_. A. 15, 3 B. 3, 15 C. 1, 10 D. 10, 1 E. 1, 15

B. 3 - worst, 15 - fully alert

Which patient is most at risk for stroke? A. A 32 year old woman with a BMI of 34, who smokes and has unregulated T2DM. B. A 72 year old African American male with HTN, a family history of stroke, who currently has sickle cell anemia. C. A 60 year old Caucasian alcoholic male who eats McDonalds every night and has a cholesterol level of 220. D. A45 year old Asian woman who smokes 2 packs a day, has HTN, T2DM, and suffered a TIA last summer.

B. A 72 year old African American male with HTN, a family history of stroke, who currently has sickle cell anemia. --> 6 risk factors

The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising? A. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure. B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. C. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure. D. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.

B. A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may arise.

The nurse recognizes the presence of Cushing's triad in the patient with A. Increased pulse, irregular respiration, increased BP B. decreased pulse, irregular respiration, increased pulse pressure C. increased pulse, decreased respiration, increased pulse pressure D. decreased pulse, increased respiration, decreased systolic BP

B. Cushing's triad consists of three vital sign measures that reflect ICP and its effect on the medulla, the hypothalamus, the pons, and the thalamus. Because these structures are very deep, Cushing's triad is usually a late sign of ICP. The signs include an increasing systolic BP with a widening pulse pressure, a bradycardia with a full and bounding pulse, and irregular respirations.

Following an industrial accident in which the client sustains a severe craniocerebral trauma, the client develops the complication of diabetes insipidus. A nurse suspects this complication is occurring when observing which symptom? A. Hyperglycemia B. Large amounts of urine output C. Elevated urine specific gravity D. Decreased LOC

B. Large amounts of urine output. Why? DI occurs d/t lack of ADH, a hormone secreted by the posterior pituitary gland. With a head injury, there may be compression of the pituitary gland and loss of ADH production.

This doctrine states that an increase in volume of one component (brain, blood, or CSF) will elevate pressure and decrease the volume of one of the other elements. A. Sterling's Law B. Monroe Kellie C. Cushing's Triad D. Homeostasis E. Parker Lewis

B. Monroe Kellie

A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. Which is the priority nursing assessment? A. Current medications. B. Time of onset of current stroke. C. Complete physical and history. D. Upcoming surgical procedures.

B. Time of onset of current stroke.

In this procedure, a balloon is inserted into a stenosed artery in the brain, and a stent is placed in the artery to improve patency and increase blood flow. A. carotid endartectomy B. angioplasty with stent C. mechanical embolus removal in cerebral ischemia (MERCI) D. CT angiography

B. angioplasty with stent

The Glasgow coma scale is an objective neurological scale aimed at recording the conscious state of a person for __(1)__ and __(2)___ assessment after a brain injury. A. (1) acute, (2) subacute B. (1) AM, (2) PM C. (1) initial, (2) subsequent

C. (1) initial, (2) subsequent

A Glasgow coma scale score of at least ____ indicates coma. A. 10 B. 9 C. 8 D. 12 E. 2

C. 8

A post-stroke patient's BP is 142/90. What medication will the doc likely prescribe? Select all that apply. A. Furosemide B. Digoxin C. Beta blocker D. Calcium channel blocker E. Aspirin 81mg

C. Beta blocker D. Calcium channel blocker

A nurse is MOST concerned about ocular signs of increased ICP because: A. It is a sign of the brain shifting from the midline & compressing the trunk of Cranial Nerve IV, causing paralysis of muscle that control the pupil size/shape. B. It puts the patient at greater risk of falls C. If a brain shift is confirmed and patient has a unilateral, dilated pupil, it could indicate herniation. D. The patient will likely experience grand mal seizures that could lead to a coma.

C. If a brain shift is confirmed and patient has a unilateral, dilated pupil, it could indicate herniation. --> THIS IS A MEDICAL EMERGENCY --> DEATH!!!

A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons? A. To reduce intraocular pressure B. To prevent acute tubular necrosis C. To promote osmotic diuresis to decrease ICP D. To draw water into the vascular system to increase blood pressure

C. Mannitol promotes osmotic diuresis by increasing the pressure gradient, drawing fluid from intracellular to intravascular spaces. Although mannitol is used for all the reasons described, the reduction of ICP in this client is a concern.

The earliest signs of increased ICP the nurse should assess for include: A. Cushing's triad B. unexpected vomiting C. decreasing level of consciousness (LOC) D. dilated pupil with sluggish response to light

C. One of the most sensitive signs of increased intracranial pressure (ICP) is a decreasing LOC. A decrease in LOC will occur before changes in vital signs, ocular signs, and projectile vomiting occur

A client is diagnosed with a stroke that affects the right hemisphere of the brain. A nurse, receiving report prior to care of this client, should expect the client to have which symptom? A. Right hemiparesis B. Expressive aphasia C. Poor impulse control D. Marked anxiety when learning new tasks

C. Poor impulse control

A 78 year old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority? A. Discuss the precipitating factors that caused the symptoms. B. Notify the speech pathologist for an emergency consult. C. Schedule for A STAT computer tomography (CT) scan of the head. D. Prepare to administer recombinant tissue plasminogen activator (rt-PA).

C. Schedule for A STAT computer tomography (CT) scan of the head.

In this stage of brain injury, compensatory mechanisms fail & ICP increases. A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 E. Stage 5

C. Stage 3

A nurse is helping a stable patient who is post-op day 4 from a ventriculostomy sit up in bed. Which of the following actions by the nurse indicates a need for further education on ventriculostomy care? A. The nurse assess the insertion site for signs of infection using aseptic technique. B. The nurse monitors the CSF for change in drainage color. C. The nurse ensures that the transducer is level with the patient's jaw every time the patient is repositioned, and frequently assesses that it is level. D. The nurse checks the patient's response to intravascular medication immediately after and 15 minutes after administration.

C. The nurse ensures that the transducer is level with the patient's jaw every time the patient is repositioned, and frequently assesses that it is level. --> FALSE! You want to make sure that you keep the transducer at the level of the forearm of Monro (TRAGUS OF THE EAR).

The medical team needs to determine whether an occlusion in the cerebral vessels is causing an increase in ICP in a patient who was just admitted in the ER. The diagnostic test that will best provide the information the medical team needs is: A. CT or MRI B. Electroencephalogram C. Cerebral angiography D. Ventriculostomy

C. cerebral angiography Key word here is "angio" --> related to blood vessels

The doctor has ordered an EEG for a patient who experienced a hockey-related concussion. The nurse knows that the purpose of an EEG is to: A. differentiate the cause of a potential ICP B. check fro problems with the electrical activity in the heart C. detect electrical activity in the brain D. check the patency of blood vessels

C. detect electrical activity in the brain

Loss of muscle control of speech is termed: A. receptive aphasia B. dysphasia C. dysarthria D. expressive aphasia E. apraxia

C. dysarthria

A patient who is recovering from a stroke is unable to both understand what the nurse is saying and express himself. This is termed: A. receptive aphasia B. expressive aphasia C. global aphasia D. dysphasia E. dysarthria F. apraxia

C. global aphasia

In promoting health maintenance for prevention of strokes, the nurse understands that the highest risk for the most common type of stroke is present in A. African Americans B. individuals who smoke C. individuals with hypertension D. those who are obese with high dietary fat intake

C. individuals with hypertension

The neurologic functions that are affected by a stroke are primarily related to: A. the amount of tissue area involved B. the rapidity of onset of symptoms C. the brain area perfused by the affected artery D. the presence or absence of collateral circulation

C. the brain area perfused by the affected artery

Which intervention should the nurse delegate to the LPN when caring for a patient following an acute stroke? A. assess the patient's neurologic status B. assess the patient's gag reflex before beginning feeding C. administer ordered antihypertensives and platelet inhibitors D. teach the patient's caregivers strategies to minimize unilateral neglect

C: Administer ordered antihypertensives and platelet inhibitors Medication administration is within the scope of practice for an LPN. Assessment and teaching are within the scope of practice for the RN.

The incidence of ischemic stroke in patients with TIAs and other risk factors is reduced with administration of A. furosemide (Lasix) B. lovastatin (Mevacor) C. daily low dose aspirin D. nimodipine (Nimotop)

C: Daily low dose aspirin The administration of antiplatelet agents, such as aspirin, dipyridamole (Persantine), and ticlopdipine (Ticlid), reduces the incidence of stroke in those at risk. Anticoagulants are also used for prevention of embolic strokes but increase the risk for hemorrhage. Diuretics are not indicated for stroke prevention other than for their role in controlling BP, and antilipemic agents have bot been found to have a significant effect on stroke prevention. The calcium channel blocker nimodipine is used in patients with subarachnoid hemorrhage to decrease the effects of vasospasm and minimize tissue damage.

A patient with a stroke has a right sided hemiplegia. The nurse prepares family members to help control behavior changes seen with this type of stroke by teaching them to A. ignore undesirable behaviors manifested by the patient B. provide directions to the patient verbally in small steps C. distract the patient from inappropriate emotional responses D. supervise all activities before allowing the patient to pursue them independently

C: Distract the patient from inappropriate emotional responses- patients with left-sided brain damage from stroke often experience emotional lability, inappropriate emotional responses, mood swings, and uncontrolled tears or laughter disproportionate or out of context with the situation. The behavior is upsetting and embarrassing to both the patient and the family, and the patient should be distracted to minimize its presence. Patients with right-brain damage often have impulsive, rapid behavior that supervision and direction.

A carotid endarterectomy is being considered as a treatment for a patient who has had several TIAs. The nurse explains to the patient that this surgery A. is used to restore blood to the brain following an obstruction of a cerebral artery B. involves intracranial surgery to join a superficial extracranial artery to an intracranial artery C. involves removing an atherosclerotic plaque in the carotid artery to prevent an impending stroke D. is sued to open a stenosis in a carotid artery with a balloon and stent to restore cerebral circulation

C: Involves removing an atherosclerotic plaque in the carotid artery to prevent an impending stroke An endarterectomy is a removal of an atherosclerotic plaque, and plaque in the carotid artery may impair circulation enough to cause a stroke. A carotid endarterectomy is performed to prevent a cerebrovascular accident (CVA), as are most other surgical procedures. An extacranial-intracranial bypass involves cranial surgery to bypass a sclerotic intacranial artery. Percutaneous transluminal angioplasty uses a balloon to compress stenotic areas in the carotid and vertebrobasilar arteries and often includes inserting a stent to hold the artery open.

A patient with right hemisphere stroke has a nursing diagnosis of unilateral neglect related to sensory perceptual deficits. During the patient's rehabilitation, it is important for the nurse to A. avoid positioning the patient on the affected side B. place all objects for care on the patient's 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 patient to care consciously for the affected side Unilateral neglect, or neglect syndrome, occurs when the patient with a stroke is unaware of the affected side of the body, which puts the patient at risk for injury. During the acute phase, the affected side is cared for by the nurse with positioning and support, during rehabilitation the patient is taught to care consciously for and attend to the affected side of the body to protect it from injury. Patients may be positioned on the affected side for up to 30 minutes.

An appropriate food for a patient with a stroke who has mild dysphagia is: A. fruit juices B. pureed meat C. scrambled eggs D. fortified milkshakes

C: scrambled eggs Soft foods that provide enough texture, flavor, and bulk to stimulate swallowing should be used for the patient with dysphasia. Thin liquids are difficult to swallow, and patients may not be able to control them in the mouth. Pureed foods are often too bland and too smooth, and milk products should be avoided because they tend to increase the viscosity of mucus and increase salivation.

Which medication, if prescribed to a patient who sustained a head injury would the nurse question with the pharmacy: A. Prophylactic seizure meds B. Barbiturates (pentobarbital, thiopental) C. Antipyretics (acetaminophen) D. Mannitol E. Corticosteroids (Dexamethasone)

CORRECT: E. Corticosteroids (Dexamethasone) --> This DOES treat vasogenic edema surrounding tumors & abcesses, but you QUESTION THIS BECAUSE... not recommended for head-injured patients. A. Prophylactic seizure meds --> TRUE. You want to monitor for seizures and give prophylactic seizure meds. B. Barbiturates (pentobarbital, thiopental) --> TRUE! decreases cerebral metabolism to decrease ICP & cerebral edema C. Antipyretics (acetaminophen) --> TRUE! Cools down temp to decrease swelling. D. Mannitol --> TRUE! Osmotic that prevents reabsorption of Na+ and water so fluid moves BACK INTO THE VESSELS to DECREASE TOTAL BRAIN FLUID CONTENT

A man notices that his mother's face looks uneven, her arm drifts down, her speech is slurred, and she cannot fully comprehend what he is saying. What should the son do next?

Call 911! This could be a stroke!

A patient was diagnosed with a left cerebral hemorrhage. Which topics are most appropriate for the nurse to include in patient and family teaching? Select all that apply. A. how to use a sign board B. transfer techniques C. information about impulse control D. time adjustment to complete activities E. safety precautions for transferring

Correct Answer: A. how to use a sign board B. transfer techniques D. time adjustment to complete activities E. safety precautions for transferring Rationale: The left cerebral hemisphere is responsible for the language center, calculation skills, and thinking/reasoning abilities. Reading and speaking could be compromised if there is left-sided brain damage. The patient also might display overcautious behavior and might be slow to respond or complete activities. Transfer techniques would apply regardless of the side involved. Impulse control problems can arise with right-sided involvement.

A post-stroke patient is going home on oral Coumadin (warfarin). During discharge teaching, which statement by the patient reflects an understanding of the effects of this medication? A. "I will stop taking this medicine if I notice any bruising." B. "I will not eat spinach while I'm taking this medicine." C. "It will be OK for me to eat anything, as long as it is low fat." D. "I'll check my blood pressure frequently while taking this medication."

Correct Answer: B. "I will not eat spinach while I'm taking this medicine." Rationale: Warfarin is a vitamin K antagonist. Green, leafy vegetables contain vitamin K, and will therefore interfere with the therapeutic effects of the drug. Bruising is a common side effect, and the drug should not be stopped unless by prescriber order. Low-fat foods do not interfere with warfarin therapy, which is not prescribed to affect the blood pressure.

A nurse is teaching a wellness class and is covering the warning signs of stroke. A patient asks, "What is the most important thing for me to remember?" Which is an appropriate response by the nurse? A. "Know your family history." B. "Keep a list of your medications." C. "Be alert for sudden weakness or numbness." D. "Call 911 if you notice a gradual onset of paralysis or confusion."

Correct Answer: C. "Be alert for sudden weakness or numbness." Rationale: Warning signs of stroke include sudden weakness, paralysis, loss of speech, confusion, dizziness, unsteadiness, and loss of balance the key word is sudden. Family history and past medical history can be indicators for risk, but they are not warning signs of stroke. Gradual onset of symptoms is not indicative of a stroke.

The nurse is caring for a patient with increased intracranial pressure (ICP). The nurse realizes that some nursing actions are contraindicated with ICP. Which nursing action should be avoided? A. Reposition the patient every two hours. B. Position the patient with the head elevated 30 degrees. C. Suction the airway every two hours per standing orders. D. Provide continuous oxygen as ordered.

Correct Answer: C. Suction the airway every two hours per standing orders. Rationale: Suctioning further increases intracranial pressure; therefore, suctioning should be done to maintain a patent airway but not as a matter of routine. Maintaining patient comfort by frequent repositioning as well as keeping the head elevated 30 degrees will help to prevent (or even reduce) ICP. Keeping the patient properly oxygenated may also help to control ICP.

The nurse recognizes that the most common type of brain attack (CVA) is related to which of the following? A. ischemia B. hemorrhage C. headache D. vomiting

Correct Answer: A. ischemic Rationale: Eighty percent of all strokes are caused by ischemia. Hemorrhagic strokes are less common than ischemic strokes. Headache and vomiting may be symptoms associated with CVA, but not common causes.

The family of a patient who has had a brain attack (CVA) asks if the patient will ever talk again. The nurse should do which of the following? A. Explain that the patient's speech will return to normal with time. B. Explain that it is difficult to know how far the patient will progress. C. Tell the family that nurses cannot discuss such issues. Tell them to ask the physician. D. Tell the family what they see today is all they can expect.

Correct Answer: B. Explain that it is difficult to know how far the patient will progress. Rationale: Therapeutic communication is needed. It is important to allow hope but be honest by not promising progress, since no one knows how much the patient will improve. Progress may depend on the extent and the areas affected. The nurse does not know that speech will return in time. It is not therapeutic to tell the family to ask the physician, and it does not display a professional, caring attitude.

A patient is admitted with signs of a stroke (CVA). On admission, vital signs were blood pressure 128/70, pulse 68, and respirations 20. Two hours later the patient is not awake, has a blood pressure of 170/70, pulse 52, and the left pupil is now slower than the right pupil in reacting to light. These findings suggest which of the following? A. impending brain death B. decreasing intracranial pressure C. stabilization of the patient's condition D. increased intracranial pressure

Correct Answer: D. increased intracranial pressure Rationale: Rising systolic blood pressure, falling pulse, and a pupil that has become sluggish suggest increasing intracranial pressure (IICP). This is an emergency situation that requires notification of the physician. This is an emergency situation that requires intervention as the patient's condition is becoming more unstable. Brain death is diagnosed by lack of brain waves and inability to maintain vital function.

What is the #1 drug used in stroke prevention for patients with TIA? A. Aspirin B. Clopidogrel (Plavix) C. Ticlopidrine D. Dipyridamole

Correct answer is: A. Aspirin The others drugs listed are also used in stroke prevention for TIA patients: B. Clopidogrel (Plavix) (makes blood slippery) C. Ticlopidrine (blood thinner) D. Dipyridamole (blood thinner & vasodilator)

A nurse is caring for a post-stroke client with a-fib. What should the nurse keep close by while the patient is on the unit? A. vitamin K+ B. suction C. trach kit D. loading dose of warfarin

Correct answer: A. vitamin K+ --> The patient will likely be on warfarin. K+ is the antidote because of increased risk of bleed. Incorrect: B. suction C. trach kit D. loading dose of warfarin --> FALSE! a-fib post stroke patients do NOT receive a loading dose of warfarin!

Which of the following would induce a negative impact on ICP? Select all that apply. A. BP of 110/79 B. Pneumothorax C. Intra-abdominal hypertension D. respiratory acidosis E. Temperature of 98.6 F. Rapid change in position

Correct answer: B. Pneumothorax C. Intra-abdominal hypertension D. respiratory acidosis F. Rapid change in position Incorrect: A. BP of 110/79 --> within normal limits E. Temperature of 98.6 --> within normal limits

A nurse asks the nursing student, "What is the difference between a thrombotic stroke and an embolic stroke?" Which should the nursing student include in their response? SELECT ALL THAT APPLY. A. "A thrombotic stroke occurs from direct injury to the blood vessel & the formation of a blood clot that narrows the lumen of the vessel." B. "In an embolic stroke, a clot from elsewhere is dislodged, travels to the cerebral artery & occludes it." C. "In an embolic stroke, there is bleeding into the cerebrospinal fluid-filled space on the surface of the brain." D. "Both thrombotic and embolic strokes cause an infarction because they block the flow of blood." E. "In thrombotic stroke, a weakened vessel wall ruptures, causing bleeding in the brain."

Correct: A. "A thrombotic stroke occurs from direct injury to the blood vessel & the formation of a blood clot that narrows the lumen of the vessel." B. "In an embolic stroke, a clot from elsewhere is dislodged, travels to the cerebral artery & occludes it." D. "Both thrombotic and embolic strokes cause an infarction because they block the flow of blood." Incorrect: C & E are associated with hemorrhagic stroke. C. "In an embolic stroke, there is bleeding into the cerebrospinal fluid-filled space on the surface of the brain." E. "In thrombotic stroke, a weakened vessel wall ruptures, causing bleeding in the brain."

A client is admitted to the intensive care unit with a severe stroke. The client is receiving a continuous IV infusion titrated according to the blood glucose results to control hyperglycemia. The client's spouse asks the nurse why the client is receiving insulin when the client is not diabetic. Which explanations to the client's spouse should the nurse include? SELECT ALL THAT APPLY. A. "The body reacts to stress by producing various hormones, which result in elevated glucose levels." B. "The body has less effective utilization of glucose during serious illness." C. "Insulin lessens the likelihood of brain tissue becoming swollen." D. "Use of insulin will decrease the likelihood of the patient becoming diabetic in the future." E. "A side effect of the medications administered is the development of T1DM."

Correct: A. "The body reacts to stress by producing various hormones, which result in elevated glucose levels." B. "The body has less effective utilization of glucose during serious illness." C. "Insulin lessens the likelihood of brain tissue becoming swollen."

A post stroke a-fib patient is being prescribed warfarin. What should the nurse be aware of while the patient is on this drug? SELECT ALL THAT APPLY: A. Antidote is vitamin K+ B. Warfarin interacts with aspirin C. Warfarin increases the risk of bleed D. Patients on warfarin receive a loading dose E. It will be important for the nurse to watch INR F. Full effect of warfarin takes 7-10 days G. It is relatively easy for the doctors to titrate doses H. Risk of bleeding can occur up to a week post discontinue date

Correct: A. Antidote is vitamin K+ B. Warfarin interacts with aspirin C. Warfarin increases the risk of bleed E. It will be important for the nurse to watch INR H. Risk of bleeding can occur up to a week post discontinue date Incorrect: D. Patients on warfarin receive a loading dose --> FALSE! F. Full effect of warfarin takes 7-10 days --> FALSE! It takes 3-5 days G. It is relatively easy for the doctors to titrate doses --> FALSE! It is difficult, so they make small changes (M-F 1mg, Sat-Sun 1.5 mg)

What would the nurse expect to see in a patient experiencing decerebrate posturing? A. Arms adducted and extended, with the wrists pronated and fingers flexed. B. Internal rotation & plantar flexion in lower extremities C. the legs are stiffly extended and internally rotated, with plantar flexion of the feet D. All four extremities are rigidly extended

Correct: A. Arms adducted and extended, with the wrists pronated and fingers flexed. D. All four extremities are rigidly extended

The nurse is monitoring a 4 day post-stroke patient. Which of the following will the nurse likely be monitoring? Select all that apply. A. High blood pressure B. Fluid & electrolytes C. Urinary output D. Hypoglycemia

Correct: A. High blood pressure B. Fluid & electrolytes C. Urinary output Incorrect: D. Hypoglycemia --> FALSE! The nurse will likely be monitoring for hyperglycemia b/c of its association with further brain damage

A nurse is using the NIH stroke scale to evaluate a patient. What is true about the NIH stroke scale? SELECT ALL THAT APPLY: A. It evaluates neurological status in stroke patients B. It includes facial palsy, motor of arms or leg limb, and ataxia C. It tests eye opening response, verbal responses, and motor responses and is graded on a scale of 3-15, 3 being the worst and 15 being fully alert D. It must be administered by a physician, OT, or PT. E. A score of 8 or less on the NIH scale indicates coma.

Correct: A. It evaluates neurological status in stroke patients B. It includes facial palsy, motor of arms or leg limb, and ataxia Incorrect: C. It tests eye opening response, verbal responses, and motor responses and is graded on a scale of 3-15, 3 being the worst and 15 being fully alert --> FALSE. This is the criteria for the Glasgow coma scale! D. It must be administered by a physician, OT, or PT. --> FALSE! A nurse can administer it. E. A score of 8 or less on the NIH scale indicates coma. --> FALSE! This is the criteria for the Glasgow coma scale.

Which of the following would you see in Cushing's Triad? SELECT ALL THAT APPLY: A. SBP 200 B. In Cushing's Triad, decorticate posturing is worse than decerebrate posturing, in that it indicates more serious damage to the midbrain & brain stem. C. BP of 180/40 D. HR 56 E. full bounding pulse F. Cheyne-stokes G. T 100.2

Correct: A. SBP 200 --> the body is trying to maintain cerebral profusion! C. BP of 180/40 --> widened pulse pressure E. full bounding pulse --> strong thumps! F. Cheyne-stokes --> irregular respirations G. T 100.2 --> increased temps Incorrect: B. In Cushing's Triad, decorticate posturing is worse than decerebrate posturing, in that it indicates more serious damage to the midbrain & brain stem. --> FALSE! Decerebrate posturing is worse than decorticate posturing. Think dEcErEbratE --> all the E's are EVIL! D. HR 74 --> HR drops to brady in Cushing's Triad

A nurse is orienting a new nurse to a unit. The experienced nurse evaluates that the new nurse understands information r/t a stroke resulting from a subarachnoid hemorrhage when which points are addressed by the new nurse? SELECT ALL THAT APPLY. A. Subarachnoid hemorrhage is often associated with a rupture of a cerebral aneurysm. B. Subarachnoid hemorrhage usually occurs while the client is sleeping and is noticed when the client awakens. C. Subarachnoid hemorrhage is accompanied by complaints of an extremely severe headache. D. Subarachnoid hemorrhage may be treated with thrombolytic therapy if no contraindications exist. E. Subarachnoid hemorrhage often results in blood cerebrospinal fluid (CSF). F. Subarachnoid hemorrhage causes nuchal rigidity.

Correct: A. Subarachnoid hemorrhage is often associated with a rupture of a cerebral aneurysm. C. Subarachnoid hemorrhage is accompanied by complaints of an extremely severe headache. E. Subarachnoid hemorrhage often results in blood cerebrospinal fluid (CSF). F. Subarachnoid hemorrhage causes nuchal rigidity. --> this is stiff neck. Incorrect: B. Subarachnoid hemorrhage usually occurs while the client is sleeping and is noticed when the client awakens. D. Subarachnoid hemorrhage may be treated with thrombolytic therapy if no contraindications exist.

A nurse is administering dexamethasone to a patient with meningitis that has caused an increase in ICP. What does the nurse know to be true of dexamethasone? SELECT ALL THAT APPLY: A. Works by preventing pro-inflammatory regulators, & restoring autoregulation B. Treats vasogenic edema surrounding tumors, abcesses, and head injury patients C. Monitoring of hypoglycemia and fluid Na+ levels is necessary D. Monitoring for s/s of infection is necessary E. Monitor for black/tarry stools, fatigue, ab pain, and anemia

Correct: A. Works by preventing pro-inflammatory regulators, & restoring autoregulation D. Monitoring for s/s of infection is necessary E. Monitor for black/tarry stools, fatigue, ab pain, and anemia --> TRUE! GI bleed is a side-effect of steroid use. Incorrect: B. Treats vasogenic edema surrounding tumors, abcesses, and head injury patients --> FALSE! Steroids are used in vasogenic edema surrounding tumors and abcesses, but NOT head injury. C. Monitoring of hypoglycemia and fluid Na+ levels is necessary --> FALSE! While you do monitor Na+ levels, you are monitoring for hyPERglycemia and doing BG checks

The Glasgow coma scale measures what areas? SELECT ALL THAT APPLY: A. eye opening B. balance C. verbal response D. motor response E. sensation

Correct: A. eye --> ability to open eyes C. verbal response --> ability to speak D. motor response --> ability to obey commands Incorrect: B. balance E. sensation

A nurse is has just received report on a patient experiencing decorticate posturing. What will the nurse expect to see on assessment? SELECT ALL THAT APPLY: A. flexion of the arms, wrists & fingers B. Abduction of upper extremities C. Extensor, internal rotation, & plantar flexion in lower extremities D. All 4 extremities are rigidly extended E. Hyperpronation of forearms & legs

Correct: A. flexion of the arms, wrists & fingers C. Extensor, internal rotation, & plantar flexion in lower extremities

An experienced nurse asks a new nurse what she knows about how blood flow to the brain is regulated. Which of the following responses by the new nurse is a correct response? SELECT ALL THAT APPLY: A. "The pressures in the brain are regulated by systemic arterial pressure." B. "The brain automatically adjusts the diameter of the cerebral blood vessels to the brain to maintain constant blood flow during changes in arterial BP." C. If brain compliance is low, small changes in volume create little pressure, a protective measure that decreases the risk of ischemia & infarction." D. "The Monroe-Kellie doctrine helps the total volume of brain tissue, CSF, & blood stay in balance at a constant 100%."

Correct: B. "The brain automatically adjusts the diameter of the cerebral blood vessels to the brain to maintain constant blood flow during changes in arterial BP." D. "The Monroe-Kellie doctrine helps the total volume of brain tissue, CSF, & blood stay in balance at a constant 100%." Incorrect: A. "The pressures in the brain are regulated by systemic arterial pressure." --> FALSE! The brain regulates its OWN blood flow in response to metabolic needs DESPITE fluctuations in systolic arterial pressure. C. "If brain compliance is low, small changes in volume create little pressure, a protective measure that decreases the risk of ischemia & infarction." --> FALSE! Compliance is expandability. If the brain can't expand, even the smallest change in volume creates greater pressure --> increased ICP will diminish perfusion, increase risk of ischemia & infarction!

A patient is undergoing a ventriculostomy to monitor his ICP post TBI. The nurse understands what to be true about the procedure. SELECT ALL THAT APPLY: A. The procedure is performed in the ER, and the patient remains awake during the procedure to ensure that he/she doesn't lapse into a coma. B. A specialized lead wire catheter is inserted into lateral ventricle, epidural, subarachnoid, or subdural space & connected to a stop-cock, external transducer, & CSF closed drainage system. C. A ventriculostomy is both a diagnostic & surgical procedure. D. Though a ventriculostomy facilitates sampling of CSF, it does not allow for intraventricular drug administration.

Correct: B. A specialized lead wire catheter is inserted into lateral ventricle, epidural, subarachnoid, or subdural space & connected to a stop-cock, external transducer, & CSF closed drainage system. C. A ventriculostomy is both a diagnostic & surgical procedure. Incorrect: A. The procedure is performed in the ER, and the patient remains awake during the procedure to ensure that he/she doesn't lapse into a coma.. --> FALSE! The procedure is performed in the ICU, and the patient is under general anesthesia (asleep and pain free). D. Though a ventriculostomy facilitates sampling of CSF, it does not allow for intraventricular drug administration. --> FALSE! You can both sample CSF & administer intraventricular drugs .

A nurse is evaluating therapeutic effects of the mannitol he/she administered to a TBI patient 30 minutes ago. Which of the following assessment findings would alarm the nurse? A. CSF sampling that tests positive for glucose B. ICP value of 17 C. K+ 3.3 D. Hct 39% E. decreased blood viscosity F. urine output of 50ml/hr

Correct: B. ICP value of 17

A child is being evaluated for possible increased ICP following head trauma. Which assessment finding associated with increased intracranial pressure (ICP) should a nurse report to a health-care provider? A. Increased alertness B. Widened pulse pressure C. Tachycardia D. Decreased systolic BP

Correct: B. Widened pulse pressure --> Why? A widened pulse pressure (increased systolic BP & a decreased diastolic BP) is one of the signs of Cushing's triad and indicative of ICP. Incorrect: A. Increased alertness --> FALSE. Decreased LOC is associated with Cushing's Triad C. Tachycardia --> FALSE. Bradycardia is associated with Cushing's triad. D. Decreased systolic BP --> Increased SBP is associated with Cushing's Triad

A nurse is observing for ocular signs of increased ICP in a patient with a left-sided mass lesion. What would indicate an increased ICP? A. dilation of the pupil on the right side of the mass lesion. B. Blurred or double vision C. Rapid response to light D. Ability to move the eye upward E. rigid eye lid

Correct: B. blurred or double vision Incorrect: A. dilation of the pupil on the right side of the mass lesion. --> FALSE! Dilation of the pupil will occur on the SAME side of mass. Since the patient has a left-sided mass lesion, the pupil dilation would be on the LEFT side. C. Rapid response to light --> FALSE! The nurse would see a sluggish or absent response to light D. Ability to move the eye upward --> FALSE! The patient would not have the ability to move the eye upward. E. rigid eye lid --> FALSE! The patient would experience ptsosis (droopy eyelid)

If increased ICP is not treated appropriately, what might we see in the patient? SELECT ALL THAT APPLY: A. ICP of 3 B. decreased cerebral perfusion C. hypoxia D. alkalosis E. increase in pH

Correct: B. decreased cerebral perfusion C. hypoxia

A doctor orders a CT/MRI for a patient with increased ICP. The nurse knows that the purpose of this diagnostic test is to: A. detect electrical activity in the brain B. check latency of the vessels in the brain C. differentiate the cause of ICP & the effect of treatment D. the facilitate sampling of CSF

Correct: C. differentiate the cause of ICP & the effect of treatment Incorrect: A. detect electrical activity in the brain --> FALSE! This is an EEG B. check latency of the vessels in the brain --> FALSE! This is a cerebral angiography D. the facilitate sampling of CSF --> FALSE! This is accomplished through a ventriculostomy!

A client who has had a stroke stares at a nurse but does not attempt to verbally respond to the nurse's questions. The client follows instructions without any problems. The nurse understands that the client is displaying symptoms consistent with: A. receptive aphasia B. global aphasia C. expressive aphasia D. both receptive and expressive aphasia

Correct: C. expressive aphasia

A nurse knows that in the first stage of brain injury: SELECT ALL THAT APPLY: A. the brain tries to regulate, but is not successful B. Compliance decreases, volume increases, and there is no change in ICP C. the brain adapts to the brain injury D. compliance, volume, and ICP increase E. compliance and volume increase with no change in ICP F. Cushing's Triad

Correct: C. the brain adapts to the injury E. compliance & volume increase with no change in ICP

A patient presents in the ER with facial droop, one arm drift, slurred speech, and disorientation. After O2 has been administered and the CT scan comes back indicating ischemic stroke, which therapy should the nurse anticipate administering? A. antiplatelet therapy B. anticoagulant therapy C. 325 mg of Aspirin (chewed) D. thrombolytic therapy

Correct: D. thrombolytic therapy --> Why? This is tPA clot buster and dissolves a clot at an ACUTE ONSET of clinical signs of stroke. Incorrect: A. antiplatelet therapy--> Not recommended during ACUTE ONSET of stroke b/c of risk of intracranial hemorrhage B. anticoagulant therapy --> Not recommended during ACUTE ONSET of stroke b/c of risk of intracranial hemorrhage C. 325 mg of Aspirin (chewed) --> Not recommended during ACUTE ONSET of stroke b/c of risk of intracranial hemorrhage

A nurse is performing a Glasgow coma scale on a stroke patient who is at risk for increased ICP. Which of the following should alert the nurse that something is wrong? A. A GCS reading of 13 B. The patient opens his eyes spontaneously C. The patient is oriented to time, place & person D. The patient can obey commands E. The nurse's GCS score is 4 points different from the previous nurse's reading taken just an hour ago.

Correct: E. The nurse's GCS score is 4 points different from the previous nurse's reading taken just an hour ago. --> Why? because the GCS is an OBJECTIVE neuro test. The nurse's score should reflect the same score as the previous nurse. Incorrect: A. A GCS reading of 13 --> This is a good reading. A bad GCS reading would be 8 and below (COMA) B. The patient opens his eyes spontaneously --> This is expected C. The patient is oriented to time, place & person --> This is expected D. The patient can obey commands --> This is expected

True or false. Usually when a patient experiences stroke damage affecting only one side of the hemisphere, the prognosis for stabilizing urinary and defecating functionality is still bad.

False! If only one side is damaged, the prognosis is good.

A patient has just experienced an ischemic stroke on the right side of his brain. What clinical manifestations would the nurse NOT expect to see in the patient? SELECT ALL THAT APPLY: A. Left-sided hemiplegia B. Left-sided neglect C. Patient minimizes or denies problems D. Patient is depressed and anxious because he/she is aware of their deficits E. Cannot solve math problems F. Impulsively bolts out of wheelchair G. Cannot gauge distances H. Aphasia I. Apraxia J. Impaired time concept

Correct: All of the following are s/s of left-sided brain damage, NOT right-sided D. Patient is depressed and anxious because he/she is aware of their deficits E. Cannot solve math problems H. Aphasia I. Apraxia

A patient arrives in the ER complaining of slurred speech and right-sided weakness. The doctor immediately orders a CT scan. The nurse knows that the purpose of a CT scan is to: SELECT ALL THAT APPLY. A. Visualize blood vessels to see if there's a filling defect B. Remove clot with a coiled wire C. open up a vessel to clean out occlusion D. rapidly distinguish an ischemic stroke from a hemorrhagic stroke E. tells the size and location of a stroke

Corrrect: D. rapidly distinguish an ischemic stroke from a hemorrhagic stroke E. tells the size and location of a stroke Incorrect: A. Visualize blood vessels to see if there's a filling defect --> FALSE! This is a CT angiography B. Remove clot with a coiled wire --> FALSE! This is a mechanical embolus removal in cerebral ischemia (MERCI) C. open up a vessel to clean out occlusion --> FALSE! This is a carotid endartectomy.

A patient with ICP monitoring has pressure of 12 mm Hg. The nurse understand that this pressure reflects: A. a severe decrease in cerebral perfusion pressure B. an alteration in the production of CSF C. the loss of autoregulatory control of ICP D. a normal balance between brain tissue, blood, and CSF

D. A normal balance between brain tissue, blood, and CSF- normal is 10- 15 mm Hg

A nurse plans care for a client and notes that all of the following must be completed for a client being prepared for surgery. Which intervention should the nurse complete first? A. Complete the preoperative checklist B. Assess client's preoperative vital signs C. Remove the client's rings, gold chain, and wristwatch D. Administer 10 mEq KCL IV for a serum potassium level of 3.0 mEq.

D. Administer 10 mEq KCL IV for a serum potassium level of 3.0 mEq. ABCs! Potassium is essential for heart!

Metabolic and nutritional needs of the patient with increased ICP are best met with A. enteral feedings that are low in sodium B. the simple glucose available in D5W IV solutions C. a fluid restriction that promotes a moderate dehydration D. balanced, essential nutrition in a form that the patient can tolerate

D. Balanced, essential nutrition in a form that the patient can tolerate= A patient with increased ICP is in a hypermetabolic and hypercatabolic state and needs adequate glucose to maintain fuel for the brain and other nutrients to meet metabolic needs. Malnutrition promotes cerebral edema, and if a patient cannot take oral nutrition, other means of providing nutrition should be used, such as tube feedings or parenteral nutrition. Glucose alone is not adequate to meet nutritional requirements, and 5% dextrose solutions may increase cerebral edema by lowering serum osmolarity. Patients should remain in a normovolemic fluid state with close monitoring of clinical factors such as urine output, fluid intake, serum and urine osmolality, serum electrolytes, and insensible losses.

The nurse is teaching regarding risk factors for stroke (CVA). The greatest risk factor is which of the following? A. diabetes B. heart disease C. renal insufficiency D. hypertension

D. Hypertension

A client with a deteriorating mental status after suffering a stroke has a rectal temp of 102.3. For which reason should a nurse initiate interventions to bring the temperature to a normal level? A. A normal temperature will strengthen the client's immune system against infection. B. Hyperthermia lowers the incidence of mortality C. A normal temperature will decrease the score on the Glasgow coma scale D. Hyperthermia increases the likelihood of a larger area of brain infarct.

D. Hyperthermia increases the likelihood of a larger area of brain infarct.

A nurse is instructing a patient's family on the importance of a bladder retaining program to help restore their urinary and bowel function post stroke. What teaching by the nurse indicates a knowledge deficit? Select all that apply: A. Scheduled toiling every 2 hours via bedpan, commode, or bathroom B. Encourage normal positioning for urinating C. Adequate fluids between 7am and 7pm D. Reposition the patient if you notice them squirming restlessly in bed. E. Palpating the abdomen for distention

D. Reposition the patient if you notice them squirming restlessly in bed. FALSE! This could be an indication that the patient has to go to the bathroom. Repositioning won't help them void.

A patient who is recovering from a stroke cannot complete a sequence of commands. This is termed: A. receptive aphasia B. expressive aphasia C. dysphasia D. apraxia

D. apraxia

True or false. Spatial-perceptual deficits, or difficulty judging distances, is more common in left-brain damage.

False! It is more common in right-brain damage.

A client is admitted to an intensive care unit because of a leaky cerebral aneurysm. A family member asks a nurse why the client is awakened and questioned about his orientation so frequently when he needs to rest. The nurse answers the family member based on the knowledge that the earliest sign of ICP is: A. pupillary changes B. drop in BP C. altered sensation D. changes in LOC

D. changes in LOC

What is the expected outcome of thrombolytic drug therapy? A. Prevention of hemorrhage B. Increased vascular permeability. C. Vasoconstriction. D. Dissolved emboli.

D. dissolve emboli

When is anticoagulant and anti-platelet therapy initiated in a stroke patient? A. at onset of symptoms B. 1 day post stroke C. only after aspirin has been taken D. once stroke patient has stabilized

D. once stroke patient has stabilized

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

The nurse can assist the patient and the family in coping with the long term effects of a stroke by A. informing family members that the patient will need assistance with almost all ADLs B. explaining that the patient's prestroke behavior will return as improvement progresses C. encouraging the patient and family members to seek assistance from family therapy or stroke support groups D. helping the patient and family understand the significance of residual stroke damage to promote problem solving and planning

D: Helping the patient and family understand the significance of residual stroke damage to promote problem solving and planning The patient and family need accurate and complete information about the effects of the stroke to problem solve and make plans for chronic care of the patient. It is uncommon for patients with major strokes to return completely to pre stroke function, behaviors, and role, and both the patient and family will mourn these losses. The patient's specific needs for care must be identified, and rehabilitation efforts should be continued at home. Family therapy and support groups may be helpful for some patients and families.

A patient's wife asks the nurse why her husband did not receive the clot busting medication (tPA) she has been reading about. Her husband is diagnosed with a hemorrhagic stroke. What should the nurse respond? A. He didn't arrive within the time frame for that therapy B. Not every is eligible for this drug. Has he had surgery lately? C. You should discuss the treatment of your husband with your doctor D. The medication you are talking about dissolves clots and could cause more bleeding in your husband's head

D: The medication you are talking about dissolves clots and could cause more bleeding in your husband's head tPA dissolves clots and increases the risk for bleeding. It is not used with hemorrhagic strokes. If the patient had a thrombotic/embolic stroke the time frame would be important as well as a history of surgery. The nurse should answer the question as accurately as possible and then encourage the individual to talk with the primary care physician if he or she has further questions.

Which cranial nerve controls pupil size and shape? A. CN IV B. CN I C. CN V D. CN X E. CN III

E. CN III Think, "I seeeee (eyes) threeeee"

True or false. Caucasians are more at risk for stroke compared to all other races.

False! African Americans are most at risk. Why? because they have HTN, stroke, DM, sickle cell anemia.

Who is more at risk of stroke - men or women?

men