Chapter 57.1
The brain requires a continuous supply of blood and oxygen. If it is interrupted, how quickly does cellular death occur?
5 minutes
A patient has been admitted to the hospital with acute cerebral infarction. The patient is completely paralyzed on the left side and does not recognize the hand. Other neurologic functions are normal. According to the National Institutes of Health Stroke Scale (NIHSS), what is this patient's score? Record the answer using a whole number. ___
5
The nurse finds that the patient is unable to recognize familiar objects after a stroke. What term does the nurse chart in the patient's medical record?
Agnosia
The nurse would expect to find what clinical manifestation in a patient admitted with a left-hemispheric stroke?
Impaired speech
A computed tomography (CT) scan has confirmed embolic stroke in a patient. When explaining the pathophysiology of the stroke to family members, the nurse includes all the following information. Arrange the pathophysiologic process involved in embolic stroke in the correct sequence.
Most emboli originate in the endocardial (inside) layer of the heart, with the plaque breaking off from the endocardium and entering the circulation. The embolus travels upward to the cerebral circulation and lodges where a vessel narrows or bifurcates (splits). Embolic stroke occurs when an embolus lodges in and occludes a cerebral artery, resulting in infarction and edema of the area supplied by the involved vessel.
While assessing the level of consciousness in a patient with a stroke, the nurse asks the patient the month and the patient's age. The patient knew his or her age but could not state what month it was. What score should the nurse give to the patient, using the National Institutes of Health Stroke Scale (NIHSS)? Record your answer using a whole number. ___
According to the NIHSS scale, when assessing the level of consciousness in a stroke patient, if the patient is able to answer one of the two questions correctly, then the score is 1.
The nurse is preparing a community stroke awareness program. The nurse knows that which ethnic group has the highest incidence of stroke?
African Americans
A patient is admitted with stroke. After initial assessment, the health care provider finds that the patient has spatial-perceptual alteration. Which manifestations should the nurse expect to find in the patient? Select all that apply.
Agnosia Apraxia Homonymous hemianopsia
A patient is admitted with stroke. After initial assessment, the health care provider finds that the patient has spatial-perceptual alteration. Which manifestations should the nurse expect to find in the patient? Select all that apply.
Agnosia Apraxia Homonymous hemianopsia
A patient has sustained a head injury and is suspected to have increased intracranial pressure. Which factor does the nurse recognize will improve cerebral blood flow?
An increase in hydrogen ion concentration
A nurse is screening patients who are at risk of stroke. Which tests would be appropriate to perform when screening these patients? Select all that apply.
Blood pressure Blood sugar level Serum cholesterol
A patient is suspected of having a subarachnoid hemorrhage. For which diagnostic test will the nurse prepare the patient, as the most reliable diagnostic study to identify the source of subarachnoid hemorrhage?
Cerebral angiography
A patient who sustained a stroke is to have a diagnostic test to determine cerebral blood flow. For what diagnostic test does the nurse prepare the patient?
Cerebral angiography
A patient has sustained a stroke and the nurse is scheduling diagnostic studies to assess the patient's cardiac status. Which diagnostic tests are priorities for the nurse to obtain? Select all that apply.
Chest x-ray Cardiac markers Electrocardiogram
The patient is recovering from a stroke and is confined to bed for most of the day. For which condition is this patient at risk?
Constipation
The patient has a diagnosis of stroke. What is the priority nursing diagnosis for the nurse when planning care?
Decreased intracranial adaptive capacity
Which modifiable risk factors for stroke would be most important for the nurse to include when planning a community education program?
Hypertension
A patient has sustained a stroke on the right side of the brain. What clinical manifestations does the nurse determine to be associated with this type of injury?
Impulsiveness
The nurse is planning care for a group of patients on a stroke unit. What tasks can the nurse delegate to unlicensed assistive personnel? Select all that apply.
Measuring and recording oral intake and urine/bowel output Providing oral and lip care at least every 2 hours and as needed Placing equipment needed for seizure precautions in the patient's room Assisting with positioning the patient and turning the patient at least every two hours
The nurse is planning care for a group of patients on a stroke unit. What tasks can the nurse delegate to unlicensed assistive personnel? Select all that apply.
Measuring and recording oral intake and urine/bowel output Providing oral and lip care at least every 2 hours and as needed Placing equipment needed for seizure precautions in the patient's room Assisting with positioning the patient and turning the patient at least every two hours
The patient is being transferred to a certified stroke center. What staff should be included in the care team? Select all that apply.
Radiologist Neurologist Registered nurse Radiologic technician
The patient is being transferred to a certified stroke center. What staff should be included in the care team? Select all that apply.
Radiologist Neurologist Registered nurse Radiologic technician
A patient with a stroke develops aphasia. What does the nurse suspect to be the reason for the patient's condition?
A defect in the middle cerebral artery
Which sensory-perceptual deficit is associated with left-hemispheric stroke (right hemiplegia)?
Slow and possibly fearful performance of tasks
A patient discharged from the hospital after a stroke looks at an old photograph and breaks down, crying inconsolably. What should the nurse tell the patient and the family? Select all that apply.
"Frustration and depression are common during the first year after stroke." "Be patient during recovery and do not complain about these involuntary behaviors."
A nurse is explaining the National Institutes of Health Stroke Scale (NIHSS) to a graduate nurse. Which statement best indicates that the graduate nurse understands the purpose of performing the NIHSS?
"The NIHSS evaluates the effects of a stroke."
What rate should blood flow in the brain in order to maintain normal function?
55 mL/100 g
The nurse provides care for a patient who has had a transient ischemic attack (TIA). The patient's spouse asks about the significance of the condition. How should the nurse explain a TIA?
It can be a warning of an impending stroke.
The patient is scheduled for a transcranial Doppler imaging scan. What information will this test provide?
It measures the velocity of blood flow.
Which medical condition places a patient at a higher risk for an embolic stroke?
Atrial fibrillation
The nurse is reviewing a patient's chart for factors that may have predisposed the patient to a recent stroke. Which factors placed this patient at risk for the stroke and should be included in the nurse's teaching plan? Select all that apply.
Atrial fibrillation Walks once a week Drinks three glass of red wine daily
The nurse is reviewing a patient's chart for factors that may have predisposed the patient to a recent stroke. Which factors placed this patient at risk for the stroke and should be included in the nurse's teaching plan? Select all that apply.
Atrial fibrillation Walks once a week Drinks three glass of red wine daily
A patient has suffered a stroke. Which neurologic factor will the nurse assess and record?
Level of consciousness
The patient's vitals are a blood pressure (BP) of 180/100 mm Hg, a heart rate of 100 beats/minute, a respiratory rate of 22, and a body temperature of 98.9 F. The doctor has ordered labetalol by slow intravenous (IV) push. What is recommended for BP management after a stroke?
Drugs to lower blood pressure are recommended if the BP is 220/120 mm Hg or higher.
The nurse is preparing a patient with a stroke for diagnostic testing to determine cerebral blood flow. Which tests would be of greatest benefit to obtain this information? Select all that apply.
Duplex scanning Digital subtraction angiography Transcranial Doppler ultrasonography
A nurse is explaining methods to reduce the risk of stroke to a patient. What instructions should the nurse convey to the patient? Select all that apply.
Eat a diet low in saturated fats. Maintain a normal blood pressure (BP). Limit consumption of alcohol to moderate levels.
A patient with a history of rheumatic heart disease arrives in the emergency room and informs the nurse of sudden loss of strength in the left arm without pain. The patient is unable to lift the arm and says that it "just fell." What condition should the nurse suspect?
Embolic stroke
The nurse assesses atrial fibrillation on the cardiac monitor. What type of stroke does the nurse anticipate for the patient to experience, if left without treatment?
Embolic stroke
The nurse is teaching a patient about the onset of embolic stroke. What information does the nurse include in the teaching plan?
Embolic stroke occurs rapidly.
A patient has slurred speech. Which is the correct way for the nurse to perform a quick stoke assessment?
Face drooping, arm weakness, speech difficulties, time
A patient has Broca's aphasia. Which lobe of the brain does the nurse anticipate to have been affected by a stroke?
Frontal lobe
A patient who sustained a stroke is having a severe headache, vomiting, dysphagia, dysarthria, and eye movement disturbances. What type of stroke does the nurse determine to correlate with these clinical manifestations?
Intracerebral hemorrhage
While doing a neurologic assessment of a patient who sustained a thrombotic stroke, the nurse records the score of a patient as 40 on a National Institutes of Health Stroke Scale (NIHSS). What does this score indicate?
Severe stroke
The patient is identified as having modifiable risk factors for stroke. Which of these risk factors is will the nurse include in the teaching plan?
Smoking
A nurse is updating the health history of a patient who has been admitted to the hospital with a stroke. What question should the nurse ask the patient's support person?
What was the time of onset of symptoms?
The nurse assesses a stiff neck and cranial nerve deficits in a patient with head trauma. What does the nurse suspect has occurred with this patient?
Subarachnoid hemorrhage
The nurse is caring for a patient who sustained a stroke and who is having difficulty swallowing. The nurse recorded the patient's swallowing status score as 4. What does this score indicate?
Swallowing status is mildly compromised.
The nurse is planning self-care priorities with a patient after a stroke. Rank these goals from highest to lowest priority.
The priority goal for a patient following a stroke is to attain maximum physical functioning (get out of bed), then to attain maximum self-care abilities (going to the bathroom, feeding oneself), maintain stable body functions (bladder/bowel control), maintain adequate nutrition (adequate intake of nutrients), and avoid complications (malnutrition, prevention of falls).
The patient is being evaluated for thrombolytic therapy. Which findings support the use of thrombolytic agents? Select all that apply.
There has been no head trauma for three months. The patient's blood pressure (BP) is 180/100 mm Hg. The computed tomographic (CT) scan is clear of hemorrhage.
The patient is being evaluated for thrombolytic therapy. Which findings support the use of thrombolytic agents? Select all that apply.
There has been no head trauma for three months. The patient's blood pressure (BP) is 180/100 mm Hg. The computed tomographic (CT) scan is clear of hemorrhage.
The patient was exhibiting symptoms of a stroke for two hours before the symptoms resolved. Which condition may this patient have experienced?
Transient ischemic attack
The nurse is conducting a physical assessment for a patient in the emergency room. Which finding is consistent with a left-hemispheric stroke?
Unilateral weakness of the right extremities