Chp 61 & 62-

FDA-approved thrombolytic therapy treatment window is _______hours after the onset of a stroke

3 Thrombolytic agents are used to treat ischemic stroke Dissolve the blood clot that is blocking blood flow to the brain.

A patient is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this patient is aware that an absolute contraindication for thrombolytic therapy is what? A) Evidence of hemorrhagic stroke B) Blood pressure of 180/112 C) Evidence of stroke evolution D) Previous thrombolytic therapy within the past 12 months

a

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

a

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

a

"I have the worst headache of my life" a. hemorrhagic stroke b. ischemic stroke

a Thunderclap headache, subarachnoid hemorrhage

The body temperature of an unconscious patient is never taken by which route? A.Axillary B.Mouth C.Rectal D.Tympanic

b

The nurse is preparing health education for a patient 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 complaints of a serious headache. C) Take antihypertensive medication as ordered. D) Drowsiness is normal for the first week after discharge.

c

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

d

Is the following statement true or false? Primary prevention is the best approach to avoiding hemorrhagic and ischemic stroke.

true Rationale: Primary prevention is the best method to avoid hemorrhagic and ischemic stroke through management of modifiable risk factors including controlling hypertension, consuming alcohol in moderation, exercise, no smoking, and managing diabetes.

What is agnosia? A. Failure to recognize familiar objects perceived by the senses B. Inability to express oneself or to understand language C. Inability to perform previously learned purposeful motor acts on a voluntary basis D. Impaired ability to coordinate movement, often seen as a staggering gait or postural imbalance

A. Failure to recognize familiar objects perceived by the senses

Is the following statement true or false? The earliest sign of increasing ICP is a change in LOC.

True Rationale: The earliest sign of increasing ICP is a change in LOC. Slowing of speech and delay in response to verbal suggestions are other early indicators.

What are expected patient outcomes for a patient recovering from a hemorrhagic stroke? A. Exhibits absence of vasospasm B. Residual aphasia C. One to four seizures D. Complains of visual changes

a Rationale: Expected patient outcomes for a patient recovering from a hemorrhagic stroke include absence of vasospasm, no seizures, normal speech patterns, and no visual changes

A family member brings the patient to the clinic for a follow-up visit after a stroke. The family member asks the nurse what he can do to decrease his chance of having another stroke. What would be the nurse's best answer? A) "Have your heart checked regularly." B) "Stop smoking as soon as possible." C) "Get medication to bring down your sodium levels." D) "Eat a nutritious diet.

b

A nurse is caring for a patient diagnosed with a hemorrhagic stroke. When creating this patient'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

b

The nurse is caring for a patient recovering from an ischemic stroke. What intervention best addresses a potential complication after an ischemic stroke? A) Providing frequent small meals rather than three larger meals B) Teaching the patient to perform deep breathing and coughing exercises C) Keeping a urinary catheter in situ for the full duration of recovery D) Limiting intake of insoluble fiber

b

The nurse is performing stroke risk screenings at a hospital open house. The nurse has identified four patients who might be at risk for a stroke. Which patient is likely at the highest risk for a hemorrhagic stroke? A) White female, age 60, with history of excessive alcohol intake B) White male, age 60, with history of uncontrolled hypertension C) Black male, age 60, with history of diabetes D) Black male, age 50, with history of smoking

b

When caring for a patient who had a hemorrhagic stroke, close monitoring of vital signs and neurologic changes is imperative. What is the earliest sign of deterioration in a patient with a hemorrhagic stroke of which the nurse should be aware? A) Generalized pain B) Alteration in level of consciousness (LOC) C) Tonic-clonic seizures D) Shortness of breath

b

When caring for a patient who has had a stroke, a priority is reduction of ICP. What patient 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

b 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.

Patient experiencing seizures are at risk for what 3 things? select all that apply. a. gestational diabetes b. hyopxia c. vomiting d. cardiac arrest e. pulmonary aspiration

bce

A patient diagnosed with a hemorrhagic stroke has been admitted to the neurologic ICU. The nurse knows that teaching for the patient and family needs to begin as soon as the patient is settled on the unit and will continue until the patient 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 patient's medication dosages at home

c

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

d

A patient with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this patient? A) Range-of-motion exercises to prevent contractures B) Encouraging independence with ADLs to promote recovery C) Early initiation of physical therapy D) Absolute bed rest in a quiet, nonstimulating environment

d

The public health nurse is planning a health promotion campaign that reflects current epidemiologic trends. The nurse should know that hemorrhagic stroke currently accounts for what percentage of total strokes in the United States? 21. A) 43% B) 33% C) 23% D) 13%

d

What intervention would not be included in aspiration precautions for a patient in the acute phase of a stroke? A. Referral to speech therapy B. Have patient tuck their chin toward the chest when swallowing C. Thickened fluids or pureed diet D. Raise HOB to 30 degrees when feeding

d