Chapter 49. Nursing Care of Patients With Cerebrovascular Disorders

A patient began experiencing manifestations of a stroke at 0800 hours. By which time should thrombolytic medications be provided to reverse stroke symptoms? 1. 0900 hours 2. 1250 hours 3. 1400 hours 4. 1660 hours

1250 hours

The nurse is providing care for a patient diagnosed with a cerebral aneurysm and subarachnoid hemorrhage. Which statement by the patient indicates a need for additional information? 1. "The doctors are going to do studies to see if I can have surgery." 2. "I know that I will be on some restrictions to prevent a rebleed." 3. "No strenuous activity until this condition is cured by surgery." 4. "It is very important to take my blood pressure medicine."

2. "I know that I will be on some restrictions to prevent a rebleed."

The nurse is preparing to assist a patient with eating who is recovering from a stroke. Which intervention is appropriate? 1. Have the patient sip liquids in small amounts with a straw. 2. Place the patient in a semi-Fowler's position to promote swallowing. 3. Check the patient's mouth periodically for presence of pocketed food. 4. Instruct the patient to swallow numerous times to clear food from the mouth.

3. Check the patient's mouth periodically for presence of pocketed food.

The nurse is providing care for a patient diagnosed with an ischemic stroke on the left side of the brain. The nurse notices that the patient does not easily locate items placed at the bedside. In which area does the nurse place items 1. On the left side 2. Directly in front 3. the right side 4. As the patient wants

3. the right side

The nurse is reviewing the medical records of patients in an HCP's practice. Which patient does the nurse recognize as the greatest risk for a stroke? 1. A postmenopausal patient who has type 2 diabetes mellitus (DM) controlled by diet 2. An overweight male with a 15-year smoking history, who is treated for hypertension 3. A young adult born with a heart defect causing ventricle fibrillation 4. An older female patient who has osteoporosis, a femur fracture, and hyperlipidemia

4. An older female patient who has osteoporosis, a femur fracture, and hyperlipidemia

A patient arrives at the emergency department and states, "Something is wrong. I just don't feel right." Which objective data causes the nurse to suspect the patient is experiencing some type of stroke? 1. Symptoms have been increasing in severity for several days. 2. Ataxia is present when the patient attempts to ambulate. 3. The patient was diagnosed with hypertension managed with medication. 4. The patient appears upset and cries easily throughout assessment.

Ataxia is present when the patient attempts to ambulate.

The nurse is aware that children can be at risk for an embolic stroke. Which condition is least likely to cause a child to have a stroke 1. Contact sport trauma 2. Sickle cell disease 3. Hyperlipidemia 4. Congenital heart defect

Contact sport trauma

The nurse is assisting the registered nurse (RN) in providing care for a patient who is recovering from a stroke. Which assigned intervention by the RN will the nurse question? 1. Observe the patient performing active range of motion (ROM) on the affected side. 2. Assist with maintaining correct body alignment for comfort. 3. Support affected extremities with pillows to prevent dislocation. 4. Follow the physical therapist's (PT's) recommendations for being up in a bedside chair.

Observe the patient performing active range of motion (ROM) on the affected side.

The nurse is assisting with the care of a patient following an ischemic stroke who does not qualify for tPA therapy. The patient's current blood pressure is 190/110 mm Hg. For which reason will the patient's hypertension remain untreated? 1. The elevated blood pressure will create collateral circulation in the brain. 2. Therapeutic blood pressure needs to exceed 220/120 mm Hg to be effective. 3. Permissive hypertension is being therapeutically used to salvage brain tissue. 4. Hypertension will move the clot to an area of the brain treatable by tPA.

Permissive hypertension is being therapeutically used to salvage brain tissue.

patient is recovering from a stroke. The family reports to the nurse that the patient alternates between periods of crying for no given reason to periods of laughing inappropriately. Which condition does the nurse suspect the patient is exhibiting?

Pseudobulbar effect

The nurse is providing care for a patient diagnosed with a stroke resulting in language disorder. Which type of disorder does the nurse recognize if the patient raises an arm in response to the nurse's direction to stick out his tongue? 1. Dysarthria 2. Expressive aphasia 3. Dysphasia 4. Receptive aphasia

Receptive aphasia

A patient comes into the emergency department with unilateral paralysis, aphasia, and inability to follow directions. Which emergency management by the health care provider (HCP) is unexpected by the nurse? 1. Maintenance of oxygen therapy to a saturation of at least 94 percent 2. Careful monitoring of changes in the patient's level of consciousness 3. Scheduling laboratory tests, electrocardiogram (ECG), and computerized tomography (CT) scan to be performed within 45 minutes 4. Immediate treatment for temperature greater than 99.6°F

Scheduling laboratory tests, electrocardiogram (ECG), and computerized tomography (CT) scan to be performed within 45 minutes

The patient is diagnosed with a cerebral vascular accident that has the slowest rate of recovery and the highest probability of causing extensive neurologic deficits. For which type of stroke does the nurse plan care for this patient? 1. Thrombotic stroke 2. Cerebral aneurysm 3. Subarachnoid hemorrhage (SAH) 4. Reversible ischemic neurologic deficit (RIND)

Subarachnoid hemorrhage (SAH)

A patient comes into the emergency department with symptoms of a stroke. Which medication does the nurse expect to be given to the patient if diagnostic testing confirms an ischemic stroke? 1. Heparin 2. Clopidogrel 3. Warfarin 4. Tissue-type plasminogen activator (tPA)

TPA

The nurse is providing care for a patient recovering from a right hemisphere infarct who now exhibits unilateral neglect. Which nursing intervention is most important at promoting safety for this patient? 1. Encourage the patient to turn her plate for ease in self-feeding. 2. Place the call light and phone on the patient's left side. 3. Teach the patient to purposefully check the location of the left limbs. 4. Provide stimuli of all senses on the patient's affected side.

Teach the patient to purposefully check the location of the left limbs.

The HCP is preparing to discharge a patient from the hospital after a stroke. The patient is insistent on being sent to a rehabilitation center. The nurse is aware that the patient must meet which qualification to go to rehabilitation? 1. The determination to live alone and independently 2. The willingness to commit to long-term therapy 3. The ability to participate in intensive therapy 4. The acceptance of financial responsibility

The ability to participate in intensive therapy

A patient arrives in the emergency department at 0200 exhibiting the manifestations of a stroke. The patient reports going to bed at 2100 and being negative for symptoms. If the CT reveals an ischemic stroke related to a blood clot, for which reason is tPA therapy withheld? 1. The therapy is based on the time the patient went to bed. 2. The patient's symptoms have progressed too quickly. 3. The total effects of ischemia are not currently known. 4. The patient is negative for any symptoms related to intracranial pressure (ICP).

The therapy is based on the time the patient went to bed.