Chapter 57 test bank - Stroke

d. tPA Hx and manifestations indicate acute ischemic stroke & pt seen within 4.5 hours of stroke onset is likely to receive tPA.

A patient arrives in the ED with hemiparesis and dysarthria that started 2 hours previously. Pt has a hx of several TIAs. What should the nurse anticipate for this pt? a. Surgical endarterectomy b. transluminal angioplasty c. IV heparin drip admin d. tPA infusion

c. start labetalol drip to keep BP under 140/90 Since elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if MAP is greater than 130.

A pt admitted w/possible stroke has been aphasic for 3 hours and current BP 174/94. Which order by HCP should nurse question? a. Keep HOB elevated 30 degrees b. infuse NS IV at 75 mL/hr c. Start labetalol drip to keep BP under 140/90 d. Begin tPA IV per protocol

D. difficulty comprehending instructions Right sided paralysis indicates a LEFT brain stroke, which leads to difficulty w/comprehesnsion & use of language. The left sided reflexes are likely in tact. Impulsive behavior and neglect are more likely w/right-side stroke

A pt being admitted w/a stroke has right-sided facial drooping & right-sided arm and leg paralysis. Which finding should the nurse expect? a. Impulsive behavior b. Right-sided neglect c. Hyperactive left-sided DTRs d. Difficulty comprehending instructions

a. apply intermittent pneumatic compression stockings

A pt has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will the nurse include in the plan of care? a. apply intermittent pneumatic compression stockings b. assist to dangle on edge of bed and assess for dizziness c. encourage pt to cough and deep breathe q4 hours d. insert an OPA to prevent airway obstruction

d. the pt takes warfarin

A pt in the ED w/sudden-onset right-sided weakness is dx w/an intracerebral hemorrhage. Which info about the pt is most important to communicate to the HCP? a. The pt's speech is difficult to understand b. The pt's BP is 144/90 c. The pt takes a diuretic because of a hx of HTN d. The pt has afib and takes warfarin

B. ASA

A pt in the clinic reports a recent episode of dysphasia & left-sided weakness at home that resolved after 2 hours. What topic should the nurse anticipate teaching the pt? a. tPA b. ASA c. Warfarin d. Nimodipine

c. symptoms began w/severe HA A sudden onset HA is typical of subarachnoid hemorrhage & ASA is contraindicated. The others are not contraindications to ASA use.

A pt is being admitted w/possible stroke. Which assessment info indicates nurse should consult w/HCP before giving prescribed dose of ASA? a. dysphasia b. aFib c. Symptoms began w/severe HA d. Hx brief episodes of right-sided hemiplegia

b. assist pt to bedside commode Q2 hours

Several weeks after a stroke, a 50M has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention should be planned to begin an effective bladder training program? a. Limit fluid intake to 1200 mL daily to reduce urine volume b. Assist pt onto bedside commode Q2 hours c. Perform intermittent catheterization after each voiding to check for residual urine d. Use an external "condom" catheter to protect the skin and prevent embarrassment

c. provide support to spouse caregiver The spouse's responsibilities indicate a high risk for caregiver role strain.

The home health nurse is taking care of an 81 yo who had a stroke 2 months ago. Based on pt info shown in figure, which action should the nurse take? a. Teach about preventing hypoglycemia b. Begin processes to obtain a wheelchair c. Provide support to spouse caregiver d. Remind pt to take prescribed meds

c. Administer the prescribed short-acting insulin

The nurse is caring for a pt who has been experiencing stroke symptoms for 60 minutes. Which action can nurse delegate to a LPN/VN? a. Assess gag and cough reflexes b. determine when stroke symptoms began c. administer prescribed short-acting insulin d. Infuse the prescribed IV metoprolol

B. pt has difficulty speaking Small emboli can occur and aphasia indicates possible stroke during procedure

The nurse is caring for a pt who has just returned after having left carotid artery angioplasty & stenting. Which assessment info is of most concern for the nurse? a. HR 102 b. Pt has difficulty speaking c. BP 144/86 d. There are fine crackles at lung bases

c. denial of deficits & impulsiveness Left-sided brain would be a, b, d

What concern should the nurse anticipate for a pt who had a right hemisphere stroke? a. Right-sided hemiplegia b. Speech-language deficits c. Denial of deficits and impulsiveness d. depression and distress about disability

c. oral low-dose ASA therapy Pt's symptoms are consistent w/TIA. Continuous heparin would not be used for TIA nor would tPA. Pts symptoms not consistent w/aneurysm

What topic should the nurse anticipate teaching a pt who had a brief episode of tinnitus, diplopia and dysarthria w/no residual effects? a. cerebral aneurysm clipping b. heparin IV infusion c. oral low-dose ASA therapy d. tPA

b. call HCP if stools are tarry Clopidigrel inhibits platelet function & increases risk for GI bleed. Med doesn't affect a, c, d

What will the nurse tell the pt who has cerebral atheroslcerosis about taking clopidogrel (Plavix)? a. Monitor and record BP daily b. Call HCP if stools are tarry c. Clopidogrel will dissolve clots in cerebral arteries d. Clopidogrel will reduce cerebral artery plaque formation

b. the pt's BP is 90/50 To prevent cerebral vasospasm & maintain cerebral perfusion, BP needs to be maintained at a level higher than 90 after subarachnoid hemorrhage. Low BP indicates need for fluids. Others are typical manifestations.

Which info about the pt who had a subarachnoid hemorrhage is most important to communicate to the HCP? a. the pt reports having a stiff neck b. the pt's BP is 90/50 c. The pt reports a severe and unrelenting HA d. The CSF report shows RBCs

c. place objects on pt's left side

Which intervention should the nurse include in the plan of care for a pt w/new right-sided homonymous hemianopsia after stroke? a. apply an eye patch to the right eye b. approach the pt from the right side c. place objects on pt's left side d. teach pt that the left visual deficit will resolve

c. The pt's usual BP is 170/94

Which stroke risk factor for a 48M in the clinic is most important for the nurse to address? a. the pt is 25 lbs above the ideal weight b. The pt drinks a glass of red wine w/dinner daily c. The pt's usual BP is 170/94 d. The pt works at a desk & relaxes by watching TV

c, d, a, b ABCs first, then baseline neuro, CT to r/o hemorrhagic stroke before tPA

A 63 yo who began experiencing right arm and leg weakness is admitted to the ED. In which order will the nurse implement these actions included in the stroke protocol? a. obtain noncontrast CT b. Infuse tPA c. Administer O2 d. Use NIH stroke scale to assess pt

b. check resp rate & effort ABCs

A 70F pt w/left-sided hemiparesis arrives by ambulance to the ED. Which action should the nurse take first? a. Take the BP b. Check resp rate & effort c. Asses GCS d. Send pt for CT

A. ask yes or no questions

A female pt who had a stroke 24 hours ago has expressive aphasia. What is an appropriate nursing intervention to help the pt communicate? a. ask questions the pt can answer w/yes or no b. develop a list of words that the pt can read and practice reciting c. have the pt practice her facial and tongue exercises w/a mirror d. prevent embarrassing the pt by answering for her if she does not respond

c. assist the pt to eat w/the right hand

A left-handed pt w/left-sided hemiplegia has difficulty feeding himself. Which intervention should nurse include in the plan of care? a. provide wide variety of food choices b. provide oral care before & after meals c. assist pt to eat w/right hand d. teach the pt the "chin-tuck" technique

b. the obstructing plaque is surgically removed from inside an artery in the neck in a carotid endarterectomy, the carotid artery is incised and plaque is removed.

A pt w/carotid atherosclerosis asks nurse to describe carotid endarterectomy. Which response by nurse is accurate? a. The diseased portion of the artery is replaced w/a synthetic graft b. the obstructing plaque is surgically removed from inside an artery in the neck c. a wire is thread through an artery in the leg to the clots in the carotid artery and the clots are removed d. a catheter with a deflated balloon is positioned at the narrow area and the balloon flattens the plaque

c. CT scan

A pt w/left-sided weakness that started 60 minutes earlier is admitted to the ED and diagnostic tests are ordered. Which test should be done first? a. CBC b. Chest x-ray c. CT scan d. ECG

c. explain ASA is ordered to decrease stroke risk

A pt who has hx of a TIA has an order for ASA 160 mg/day. When the nurse is administering meds, the pt says "I don't need the aspirin today. I don't have a fever." Which action should the nurse take? a. Document that the pt refused the ASA b. Tell pt that the ASA is used to prevent a fever c. Explain ASA is ordered to decrease stroke risk d. Call HCP to clarify the medication order

c. assist the pt into a chair the pt should be as upright as possible. To assess swallowing ability, nurse should initially offer water or ice. Pureed is too smooth.

A pt will attempt oral feedings for the first time after having a stroke. After assessing the gag reflex, what action should the nurse take? a. order a varied pureed diet b. assess pt's appetite c. assist pt into chair d. offer pt a sip of juice

d. Teach family that emotional outbursts are common

A pt with left-brain stroke suddenly bursts into tears when family members visit. How should the nurse respond? a. Use a calm voice to ask the pt to stop crying behavior b. Explain to family that depression is normal following stroke c. Have family members leave pt alone for a few minutes d. Teach family that emotional outbursts are common after strokes

a. Risk for aspiration

Nurses in change of shift report are discussing the care of a pt w/a stroke who has progressively increasing weakness and decreasing LOC. Which pt problem do they determine has the highest priority for the pt? a. Risk for aspiration b. Impaired skin integrity c. Impaired physical mobility c. Disturbed sensory perception

a. pt who has an infusion of tPA prescribed

After receiving change-of-shift report on the following 4 pts, which pt should be seen first? a. 60 yo pt right-sided weakness who has an infusion of tPA prescribed b. 50 yo pt who has aFib & new order for warfarin c. 30 yo pt w/subarachnoid hemorrhage 2 days ago who has nimodipine scheduled d. 40 yo pt who had TIA yesterday and has dose of ASA due

C. visual deficits Aphasia occurs w/middle cerebral artery. Cognitive deficits & changes in judgment are more typical of anterior cerebral artery occlusion.

During change of shift report, nurse is told pt has an occluded L posterior cerebral artery. Which finding should the nurse anticipate? a. dysphagia b. confusion c. visual deficits d. poor judgment