CH. 62 Management of Patients With Cerebrovascular Disorders

A client who has experienced an ischemic stroke has been admitted to the medical unit. The client's family is adamant that the client remain on bed rest to hasten recovery and to conserve energy. What principle of care should inform the nurse's response to the family? A. The client should mobilize as soon as physically able. B. To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks. C. The client should remain on bed rest until the client expresses a desire to mobilize. D. Lack of mobility will greatly increase the client's risk of stroke recurrence.

ANS: A Rationale: As soon as possible, the client is assisted out of bed and an active rehabilitation program is started. Delaying mobility causes complications, but not necessarily stroke recurrence. Mobility should not be withheld until the client initiates.

The nurse is educating a group of nursing students about COVID-19 and risk for cerebrovascular disorders. The nurse educator notes that COVID-19 has shown to increase which condition? A. Ischemic stroke B. Decrease inflammation C. Hemorrhagic stroke D. Hypertension

ANS: A Rationale: Blood clotting abnormalities have been found to occur in COVID-19 afflicted clients. With the clotting abnormalities, there is an increased risk for ischemic stroke. There is no evidence that COVID-19 causes any of the other conditions.

A client who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurse's care of this client? A. The client should be approached on the side where visual perception is intact. B. Attention to the affected side should be minimized in order to decrease anxiety. C. The client should avoid turning in the direction of the defective visual field to minimize shoulder subluxation. D. The client should be approached on the opposite side of where the visual perception is intact to promote recovery.

ANS: A Rationale: Clients with decreased field of vision should first be approached on the side where visual perception is intact. All visual stimuli should be placed on this side. The client can and should be taught to turn the head in the direction of the defective visual field to compensate for this loss. The nurse should constantly remind the client of the other side of the body and should later stand at a position that encourages the client to move or turn to visualize who and what is in the room.

The nurse is educating a group of students about complications of an aneurysm. Which is a complication of aneurysm? A. Seizure B. Hypernatremia C. Airway collapse D. Pneumothorax

ANS: A Rationale: Due to increased intracranial pressure, there is a risk for the client developing seizures. Hyponatremia, not hypernatremia, can occur. Airway collapse and pneumothorax do not occur as a complication of an aneurysm.

When preparing to discharge a client home, the nurse has met with the family and warned them that the client may exhibit unexpected emotional responses. The nurse should teach the family that these responses are typically a result of what cause? A. Frustration around changes in function and communication B. Unmet physiologic needs C. Changes in brain activity during sleep and wakefulness D. Temporary changes in metabolism

ANS: A Rationale: Emotional problems associated with stroke are often related to the new challenges around ADLs and communication. These challenges are more likely than metabolic changes, unmet physiologic needs, or changes in brain activity, each of which should be ruled out.

The nurse is assessing a client with a suspected stroke. What assessment finding is most suggestive of a stroke? A. Facial droop B. Dysrhythmias C. Periorbital edema D. Projectile vomiting

ANS: A Rationale: Facial drooping or asymmetry is a classic abnormal finding on a physical assessment that may be associated with a stroke. Periorbital edema (swelling around the eyes) is not suggestive of a stroke, and clients less commonly experience dysrhythmias or vomiting.

Nursing care during the immediate recovery period from an ischemic stroke should normally prioritize which intervention? A. Positioning the client to avoid intercranial pressure (ICP) B. Maximizing partial pressure of carbon dioxide (PaCO2) C. Administering hypertonic intravenous (IV) solution D. Initiating early mobilization

ANS: A Rationale: Interventions during this period include measures to reduce ICP, such as administering an osmotic diuretic (e.g., mannitol) and positioning to avoid ICP, and handle secretions to avoid aspiration. Hypertonic IV solutions are not used unless sodium depletion is evident. PaCO2 must remain within an acceptable range, not maximized. Mobilization would take place after the immediate threat of increased ICP has passed.

The client has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the client's atmosphere more conducive to communication? A. Provide a board of commonly used needs and phrases. B. Have the client speak to loved ones on the phone daily. C. Help the client complete his or her sentences as needed. D. Speak in a loud and deliberate voice to the client.

ANS: A Rationale: The inability to talk on the telephone or answer a question or exclusion from conversation causes anger, frustration, fear of the future, and hopelessness. A common pitfall is for the nurse or other health care team member to complete the thoughts or sentences of the client. This should be avoided because it may cause the client to feel more frustrated at not being allowed to speak and may deter efforts to practice putting thoughts together and completing a sentence. The client may also benefit from a communication board, which has pictures of commonly requested needs and phrases. The board may be translated into several languages.

A client is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this client is aware that an absolute contraindication for thrombolytic therapy is what? A. Evidence of hemorrhagic stroke B. Blood pressure of 180/110 mm Hg C. Evidence of stroke evolution D. Previous thrombolytic therapy within the past 12 months

ANS: A Rationale: Thrombolytic therapy would exacerbate a hemorrhagic stroke with potentially fatal consequences. Stroke evolution, high BP, or previous thrombolytic therapy does not contraindicate its safe and effective use.

The nurse is caring for a client recovering from an ischemic stroke. What intervention(s) best addresses potential complications after an ischemic stroke? Select all that apply. A. Providing frequent small meals rather than three larger meals B. Teaching the client to perform deep breathing and coughing exercises. C. Keeping a urinary catheter in place for the full duration of recovery. D. Limiting intake of insoluble fiber, carbohydrates, and simple sugars. E. Encourage the client to stay in bed and assist with turning and repositioning.

ANS: A, B Rationale: Because pneumonia is a potential complication of stroke, deep breathing and coughing exercises should be encouraged unless contraindicated. Providing small frequent meals during recovery will decrease the likelihood of aspiration. Dietary restrictions are based on individual client needs, and fiber, carbohydrates, and sugars are not typically restricted. Urinary catheters should be discontinued as soon as possible to prevent the increased risk of catheter associated urinary tract infections (CAUTI). It is also important to get the client out of bed as soon as possible to prevent pressure ulcers and encourage mobility.

During a client's recovery from stroke, the nurse should be aware of predictors of stroke outcome in order to help clients and families set realistic goals. What are the predictors of stroke outcome? Select all that apply. A. National Institutes of Health Stroke Scale (NIHSS) score B. Race C. LOC at time of admission D. Gender E. Age

ANS: A, C, E Rationale: It is helpful for clinicians to be knowledgeable about the relative importance of predictors of stroke outcome (age, NIHSS score, and LOC at time of admission) to provide stroke survivors and their families with realistic goals. Race and gender are not significant predictors of stroke outcome.

A client with a recent stroke history is admitted to a rehabilitation unit and placed on high fall risk precautions. The client is impulsive, easily distracted, frequently forgets his/her cane when walking, and the location of his/her room. What stroke conditions do these signs best indicate? A. Ischemic stroke B. Right hemispheric stroke C. Hemorrhagic stroke D. Left hemispheric stroke

ANS: B Rationale. In right hemispheric stroke, signs include a client that is easily distracted and has impulsive behavior and poor judgment. The client can be unaware of deficits like motor weakness, as demonstrated by the client forgetting the cane. Clients can also have spatial or perceptual deficits. This means they can get lost in familiar and unfamiliar places. This client was unable to find his/her room. The client who has a right hemisphere stroke demonstrates weakness on the left side of the body. The client with left hemispheric stroke has signs such as paralysis or weakness in the right side of the body, right-sided visual deficits, and slow cautious behaviors. Ischemic and hemorrhagic strokes describe what caused the stroke rather than what side of the brain was affected. Signs and symptoms differ for each type of stroke. Ischemic strokes can include numbness to one side of the face. Headache, decreased level of consciousness, and seizures typically are signs of a hemorrhagic stroke.

The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration? A. Generalized pain B. Alteration in level of consciousness (LOC) C. Tonic-clonic seizures D. Shortness of breath

ANS: B Rationale: Alteration in LOC is the earliest sign of deterioration in a client after a hemorrhagic stroke, such as mild drowsiness, slight slurring of speech, and sluggish papillary reaction. Sudden headache may occur, but generalized pain is less common. Seizures and shortness of breath are not identified as early signs of hemorrhagic stroke.

The nurse is caring for a client who is known to be at risk for cardiogenic embolic strokes. What arrhythmia does this client most likely have? A. Ventricular tachycardia B. Atrial fibrillation C. Supraventricular tachycardia D. Bundle branch block

ANS: B Rationale: Cardiogenic embolic strokes are associated with cardiac arrhythmias, which is usually atrial fibrillation. Absence of a regular contraction of the fibrillating atria leads to an increase of atrial pressure and dilation, which together with hemoconcentration, endothelial dysfunction, and a prothrombotic state are prerequisites for thrombus formation. In other words, the irregularity of the heartbeat caused by atrial fibrillation makes the heart more likely to form clots. Studies have shown that strokes that are caused by atrial fibrillation have an increased poor outcome in terms of severity and resulting disability. The other listed arrhythmias are less commonly associated with this type of stroke.

A rapid response and stroke alert/code has been called for a client with deep vein thrombosis (DVT) of the left leg being treated with intravenous heparin. The client's international normalized ratio (INR) is 2.1 and vital signs are: Temperature 100.1°F (37.8°C), heart rate 102, blood pressure 190/100, respirations 14, and saturation 89% on room air. What are priority interventions for a client who is currently on anticoagulant therapy and having an ischemic stroke? A. Immediate intubation and urinary catheter placement B. Supplemental oxygen and monitoring blood glucose levels C. Antipyretics in order to keep the client in a state of hypothermia D. Antihypertensive medications and vital signs every two hours

ANS: B Rationale: Careful maintenance of cerebral hemodynamics to maintain cerebral perfusion is extremely important after a stroke. Interventions during this period include measures to reduce ICP. Other treatment measures include: Providing supplemental oxygen if saturation is below 95% and monitoring of blood glucose and management. Intubation is used only if necessary to establish a patent airway. For this client, a more expedient and less invasive measure would be supplemental oxygen. Urinary catheter placement is not a priority measure for this client. It is important to monitor for febrile events, but there is no protocol in place to keep the client hypothermic. Antihypertensive medication goals for blood pressure in the first 24 hours after a stroke remain controversial for a client who has not received thrombolytic therapy; antihypertensive treatment may be given to lower the blood pressure by 15% if the systolic blood pressure exceeds 220 mm Hg or the diastolic blood pressure exceeds 120 mm Hg. Vital signs for this client would be monitored closely and continuously until stable.

A client has recently begun mobilizing during the recovery from an ischemic stroke. To protect the client's safety during mobilization, the nurse should perform what action? A. Support the client's full body weight with a waist belt during ambulation. B. Have a colleague follow the client closely with a wheelchair. C. Avoid mobilizing the client in the early morning or late evening. D. Ensure that the client's family members do not participate in mobilization.

ANS: B Rationale: During mobilization, a chair or wheelchair should be readily available in case the client suddenly becomes fatigued or feels dizzy. The family should be encouraged to participate, as appropriate, and the nurse should not have to support the client's full body weight. Morning and evening activities are not necessarily problematic.

A nurse is caring for a client diagnosed with a hemorrhagic stroke. When creating this client's plan of care, what goal should be prioritized? A. Prevent complications of immobility. B. Maintain and improve cerebral tissue perfusion. C. Relieve anxiety and pain. D. Relieve sensory deprivation.

ANS: B Rationale: Each of the listed goals is appropriate in the care of a client recovering from a stroke. However, promoting cerebral perfusion is a priority physiologic need, on which the client's survival depends.

When caring for a client who has had a stroke, a priority is reduction of ICP. What client position is most consistent with this goal? A. Head turned slightly to the right side B. Elevation of the head of the bed C. Position changes every 15 minutes while awake D. Extension of the neck

ANS: B Rationale: Elevation of the head of the bed promotes venous drainage and lowers ICP; the nurse should avoid flexing or extending the neck or turning the head side to side. The head should be in a neutral midline position. Excessively frequent position changes are unnecessary.

A rehabilitation nurse caring for a client who has had a stroke is approached by the client's family and asked why the client has to do so much for self-care while obviously struggling to do so. What would be the nurse's best answer? A. "We are trying to help the client be as useful as possible." B. "The focus on care in a rehabilitation facility is to help the client to resume as much self-care as possible." C. "We aren't here to care for the client the way the hospital staff did; we are here to help the client get better and return home." D. "Rehabilitation means helping clients do exactly what they did before their stroke."

ANS: B Rationale: In both acute care and rehabilitation facilities, the focus is on teaching the client to resume as much self-care as possible. The goal of rehabilitation is not to be "useful," nor is it to return clients to their pre-stroke level of functioning, which may be unrealistic.

A client recently had a stroke. Now the client has spasms in his/her hands, which is preventing a favorite hobby of knitting. The client is looking for a permanent solution to this problem. Which therapies would the nurse recommend? A. Botulinum toxin type A and heat B. Baclofen and stretching C. Amitriptyline and splinting D. Corticosteroids and acupuncture

ANS: B Rationale: Treatments for spasticity may include stretching, splinting (in select clients), and oral medications such as baclofen and tizanidine. Studies concerning splitting debate the effectiveness of this treatment. Botulinum toxin type A injected intramuscularly into wrist and finger muscles has been shown to be effective in reducing this spasticity but the effect is temporary, typically lasting 2 to 4 months. Amitriptyline is more effective for post-stroke pain and depression. Corticosteroids, heat therapy, and acupuncture are recommended for shoulder pain after a client has a stroke.

A nurse is taking care of a client with swallowing difficulties after a stroke. What are some interventions the nurse can accomplish to prevent the client from aspirating while eating? Select all that apply. A. Encourage the client to increase his/her intake of water and juice. B. Assist the client out of bed and into the chair for meals. C. Instruct the client to tuck his/her chin towards their chest when swallowing. D. Request a swallowing assessment by a speech therapist before the client's discharge E. Recommend the insertion of a percutaneous endoscopic gastrostomy (PEG) tube.

ANS: B, C Rationale: If swallowing function is partially impaired, it may return over time, or the client may be educated in alternative swallowing techniques, advised to take smaller boluses of food, and educated about types of foods that are easier to swallow. The client may be started on a thick liquid or pureed diet, because these foods are easier to swallow than thin liquids. Having the client sit upright, preferably out of bed in a chair, and instructing them to tuck the chin toward the chest as they swallow will help prevent aspiration. Recommending the insertion of a percutaneous endoscopic gastrostomy (PEG) tube would not prevent the client from aspirating while eating. A PEG tube could be placed if the client was unable to tolerate or resume an oral intake. A swallowing assessment should be done before allowing any oral intake and preferably within 4 to 24 hours after a stroke. A nurse can also accomplish a swallowing study using a validated and reliable assessment tool.

A nurse is assisting a client who had a recent stroke with getting dressed for physical therapy. The client looks at each piece of clothing before putting it on the body. The client states, "This is how I know what item I am holding." What impairment is this client likely experiencing? A. Homonymous hemianopsia B. Receptive aphasia C. Agnosia D. Hemiplegia

ANS: C Rationale: Agnosia is the loss of the ability to recognize objects through a particular sensory system; it may be visual, auditory, or tactile. The client was able to see what was being held but was not recognizing specific garments by just touching them. Because the client was able to see homonymous hemianopsia, which is blindness in half of the visual field in one or both eyes, is unlikely. Receptive aphasia is an inability to understand language. Hemiplegia is a motor/ambulatory dysfunction. The presented scenario did not support these findings.

A client with a left hemispheric stroke is having difficulty with their normal speech patterns. The nurse is not sure whether the client has expressive aphasia or apraxia. Which statement would most likely be reflective of apraxia? A. The nurse gives direction to get out of bed but the client does not understand. B. The client points and gestures to an object needed on the overhead table. C. The client starts by saying "good morning" but finishes with saying "good day" to the nurse. D. The client sits up and turns to one side to see the object and states what is needed.

ANS: C Rationale: Apraxia is an inability to perform a previously learned action as may be seen when a client makes verbal substitutions for desired syllables or words. The client changed "good morning" to "good day," which is suggestive of this condition. Aphasia which can be expressive aphasia (inability to express oneself) or receptive aphasia (inability to understand language) is more likely represented with the client being unable to understand directions to get out of bed and by pointing and gesturing to an object needed rather than speaking. The client turning to one side so he/she can see the object may be more indicative of blindness to one side (homonymous hemianopsia).

A client with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the client's cardiac and neurologic status, the nurse monitors the client for signs of what complication? A. Acute pain B. Septicemia C. Bleeding D. Seizures

ANS: C Rationale: Bleeding is the most common side effect of t-PA administration, and the client is closely monitored for any bleeding. Septicemia, pain, and seizures are much less likely to result from thrombolytic therapy.

The nurse is discharging home a client who had a stroke. The client has a flaccid right arm and leg and is experiencing urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common client response to a change in body image? A. Confusion B. Uncertainty C. Depression D. Disassociation

ANS: C Rationale: Depression is a common and serious problem in the client who has had a stroke. It can result from a profound disruption in his or her life and changes in total function, leaving the client with a loss of independence. The nurse needs to encourage the client to verbalize feelings to assess the effect of the stroke on self-esteem. Confusion, uncertainty, and disassociation are not the most common client response to a change in body image, although each can occur in some clients.

A client diagnosed with a hemorrhagic stroke has been admitted to the neurologic ICU. The nurse knows that teaching for the client and family needs to begin as soon as the client is settled on the unit and will continue until the client is discharged. What will family education need to include? A. How to differentiate between hemorrhagic and ischemic stroke B. Risk factors for ischemic stroke C. How to correctly modify the home environment D. Techniques for adjusting the client's medication dosages at home

ANS: C Rationale: For a client with a hemorrhagic stroke, teaching addresses the use of assistive devices or modification of the home environment to help the client live with the disability. This is more important to the client's needs than knowing about risk factors for ischemic stroke. It is not necessary for the family to differentiate between different types of strokes. Medication regimens should never be altered without consultation.

The nurse is caring for a client diagnosed with an ischemic stroke and knows that effective positioning of the client is important. Which of the following should be integrated into the client's plan of care? A. The client's hip joint should be maintained in a flexed position. B. The client should be in a supine position unless ambulating. C. The client should be placed in a prone position for 15 to 30 minutes several times a day. D. The client should be placed in a Trendelenburg position two to three times daily to promote cerebral perfusion.

ANS: C Rationale: If possible, the clients placed in a prone position for 15 to 30 minutes several times a day. A small pillow or a support is placed under the pelvis, extending from the level of the umbilicus to the upper third of the thigh. This helps to promote hyperextension of the hip joints, which is essential for normal gait, and helps prevent knee and hip flexion contractures. The hip joints should not be maintained in flexion and the Trendelenburg position is not indicated.

The nurse is reviewing the medication administration record of a client who possesses numerous risk factors for stroke. Which of the client's medications carries the greatest potential for reducing her risk of stroke? A. Naproxen 250 PO b.i.d. B. Calcium carbonate 1,000 mg PO b.i.d. C. Aspirin 81 mg PO o.d. D. Lorazepam 1 mg SL b.i.d. PRN

ANS: C Rationale: Research findings suggest that low-dose aspirin may lower the risk of stroke in clients who are at risk. Naproxen, lorazepam, and calcium supplements do not have this effect.

The nurse is preparing health education for a client who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in this education? A. Mild, intermittent seizures can be expected. B. Take ibuprofen for a serious headache. C. Take antihypertensive medication as prescribed. D. Drowsiness is normal for the first week after discharge.

ANS: C Rationale: The client and family are provided with information that will enable them to cooperate with the care and restrictions required during the acute phase of hemorrhagic stroke and to prepare the client to return home. Client and family teaching includes information about the causes of hemorrhagic stroke and its possible consequences. Symptoms of hydrocephalus include gradual onset of drowsiness and behavioral changes. Hypertension is the most serious risk factor, suggesting that appropriate antihypertensive treatment is essential for a client being discharged. Seizure activity is not normal; reports of a serious headache should be reported to the health care provider before any medication is taken. Drowsiness is not normal or expected.

The pathophysiology of an ischemic stroke involves the ischemic cascade, which includes the following steps. Place the steps in the order in which they occur. All options must be used. 1. Change in pH 2. Blood flow decreases 3. A switch to anaerobic respiration 4. Membrane pumps fail 5. Cells cease to function 6. Lactic acid is generated A. 6,3,5,2,4,1 B. 3,5,2,4,1,6 C. 2,3,6,1,4,5 D. 1,6,2,5,3,4

ANS: C Rationale: The ischemic cascade begins when cerebral blood flow decreases to less than 25 mL per 100 g of blood per minute. At this point, neurons are no longer able to maintain aerobic respiration. The mitochondria must then switch to anaerobic respiration, which generates large amounts of lactic acid, causing a change in the pH. This switch to the less efficient anaerobic respiration also renders the neuron incapable of producing sufficient quantities of adenosine triphosphate (ATP) to fuel the depolarization processes. The membrane pumps that maintain electrolyte balances begin to fail, and the cells cease to function.

A client diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for which purpose? A. To decrease cerebral edema B. To prevent seizure activity that is common following a TIA C. To remove atherosclerotic plaques blocking cerebral flow D. To determine the cause of the TIA

ANS: C Rationale: The main surgical procedure for select clients with TIAs is carotid endarterectomy, the removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in clients with occlusive disease of the extracranial arteries. An endarterectomy does not decrease cerebral edema, prevent seizure activity, or determine the cause of a TIA.

A nurse is educating a group of nursing students about signs and symptoms of a hemorrhagic stroke. Which is true of hemorrhagic stroke? A. Occurs with vascular occlusion. B. Is also known as thrombotic stroke. C. Can be known as lacunar strokes. D. Can occur in the subarachnoid space.

ANS: D Hemorrhagic strokes take place in either the brain or subarachnoid space. The occurrence of vascular occlusion, the identification as thrombotic stroke or lacunar stroke are associated with ischemia strokes.

A client diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse? A. Sit with the client for a few minutes. B. Administer an analgesic. C. Inform the nurse manager. D. Call the health care provider immediately.

ANS: D Rationale: A headache may be an indication that the aneurysm is leaking. The nurse should notify the health care provider immediately. The health care provider will decide whether administration of an analgesic is indicated. Informing the nurse manager is not necessary. Sitting with the client is appropriate, once the health care provider has been notified of the change in the client's condition.

A client with an ischemic stroke has been brought to the emergency room. The health care provider institutes measures to restore cerebral blood flow. What area of the brain would most likely benefit from this immediate intervention? A. Cerebral cortex B. Temporal lobe C. Central sulcus D. Penumbra region

ANS: D Rationale: In an ischemic stroke, there is disruption of the cerebral blood flow due to obstruction of a blood vessel. This disruption in blood flow initiates a complex series of cellular metabolic events referred to as the ischemic cascade. Early in the cascade, an area of low cerebral blood flow, referred to as the penumbra region, exists around the area of infarction. The penumbra region is ischemic brain tissue that may be salvaged with timely intervention. The cerebral cortex, temporal lobe, and central sulcus are all different areas of the brain. Since the specific area was not identified in the scenario; the area that would most benefit from immediate interventions would be the area surrounding the infarct called the penumbra region.

What should be included in the client's care plan when establishing an exercise program for a client affected by a stroke? A. Schedule passive range of motion every other day B. Keep activity limited, as the client may be overstimulated. C. Have the client perform active range-of-motion (ROM) exercises once a day. D. Exercise the affected extremities passively four or five times a day.

ANS: D Rationale: The affected extremities are exercised passively and put through a full ROM four or five times a day to maintain joint mobility, regain motor control, prevent development of a contracture in the paralyzed extremity, prevent further deterioration of the neuromuscular system, and enhance circulation. Active ROM exercises should ideally be performed more than once per day.

A client with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this client? A. Passive range-of-motion exercises to prevent contractures B. Supine positioning C. Early initiation of physical therapy D. Absolute bed rest in a quiet, non stimulating environment

ANS: D Rationale: The client is placed on immediate and absolute bed rest in a quiet, nonstressful environment because activity, pain, and anxiety elevate BP, which increases the risk for bleeding. Visitors are restricted. The nurse administers all personal care. The client is fed and bathed to prevent any exertion that might raise BP. Clients with increased ICP are normally positioned with the HOB elevated.

A nursing student is writing a care plan for a newly admitted client who has been diagnosed with a stroke. What major nursing diagnosis should most likely be included in the client's plan of care? A. Adult failure to thrive B. Post-trauma syndrome C. Hyperthermia D. Disturbed sensory perception

ANS: D Rationale: The client who has experienced a stroke is at a high risk for disturbed sensory perception. Stroke is associated with multiple other nursing diagnoses, but hyperthermia, adult failure to thrive, and post-trauma syndrome are not among these.

A client is diagnosed with a right-sided stroke. The client is now experiencing hemianopsia. How might the nurse help the client manage the potential sensory and perceptional difficulties? A. Keep the lighting in the client's room low. B. Place the client's clock on the affected side. C. Approach the client on the side where vision is impaired. D. Place the client's extremities where the client can see them.

ANS: D Rationale: The client with homonymous hemianopsia (loss of half of the visual field) turns away from the affected side of the body and tends to neglect that side and the space on that side; this is called amorphosynthesis. In such instances, the client cannot see food on half of the tray, and only half of the room is visible. It is important for the nurse to remind the client constantly of the other side of the body, to maintain alignment of the extremities, and if possible, to place the extremities where the client can see them. Clients with a decreased field of vision should be approached on the side where visual perception is intact. All visual stimuli (clock, calendar, and television) should be placed on this side. The client can be taught to turn the head in the direction of the defective visual field to compensate for this loss. Increasing the natural or artificial lighting in the room and providing eyeglasses are important in increasing vision. There is no reason to keep the lights dim.

A client recovering from a stroke has severe shoulder pain from subluxation of the shoulder. To prevent further injury and pain, the nurse caring for this client is aware of what principle of care? A. The client should be fitted with a cast because use of a sling should be avoided due to adduction of the affected shoulder. B. Elevation of the arm and hand can lead to further complications associated with edema. C. Passively exercising the affected extremity is avoided in order to minimize pain. D. The client should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder.

ANS: D Rationale: To prevent shoulder pain, the nurse should never lift a client by the flaccid shoulder or pull on the affected arm or shoulder. The client is taught how to move and exercise the affected arm/shoulder through proper movement and positioning. The client is instructed to interlace the fingers, place the palms together, and push the clasped hands slowly forward to bring the scapulae forward; he or she then raises both hands above the head. This is repeated throughout the day. The use of a properly worn sling when the client is out of bed prevents the paralyzed upper extremity from dangling without support. Range-of-motion exercises are still vitally important in preventing a frozen shoulder and ultimately atrophy of subcutaneous tissues, which can cause more pain. Elevation of the arm and hand is also important in preventing dependent edema of the hand.