HIT II: Neurologic Function (PART 2)

tPA dosage:

0.9 mg/kg

tPA 10% of the dose is bolused over ____.

1 minute

In healthy people, an INR of _____ is considered normal.

1.1 or below

normal prothrombin time

10-13 seconds

An INR range of ____ is generally an effective therapeutic range for people taking warfarin for disorders such as atrial fibrillation or a blood clot in the leg or lung.

2.0 to 3.0

Tissue Plasminogen Activator Administration (tPA) therapy is given within ____ of stroke.

3 - 4 hours

Max dose for tPA

90 mg

Eligibility Criteria for tPA Administration Age:

> 18

What are the (3) non-modifiable risk factors for stroke?

Age > 55 Male African-american

F.A.S.T:

F: Ask the person to smile. Does one side of the face droop down? A: Ask the person to raise both arms. Does one arm drift down? S: Ask the person to repeat a simple phrase. Is their speech slurred or strange? T: Time, if you observe any of these signs → call 911 immediately

______ is used to track the changes in the functional ability of a patient during an episode of hospital rehabilitation care.

FIM

Eligibility Criteria for tPA Administration Prothrombin time ____. INR _____.

Prothrombin time ≤15 seconds INR ≤1.7

_______: the partial inability to initiate coordinated voluntary motor acts a. Dyspraxia b. Hemiplegia c. Hemiparesis

a. Dyspraxia

Hemorrhagic stroke results in (select all that apply): a. Hematoma b. Edema c. Severe drop in ICP d. Increase in WBC count e. Dramatic increase in SpO2

a. Hematoma b. Edema

Interventions for modifiable risk factors (select all that apply): a. Treat HTN b. Treat diabetes c. high-sodium diet d. exercise limitations e. high-fat diet

a. Treat HTN b. Treat diabetes

The nurse is providing information about strokes to a community group. Which of the following would the nurse identify as the primary initial symptoms of an ischemic stroke? a. Weakness on one side of the body and difficulty with speech b. Severe headache and early change in level of consciousness c. Foot drop and external hip rotation d. Vomiting and seizures

a. Weakness on one side of the body and difficulty with speech

Approximately 87% of stroke cases. Vascular occlusion and significant hypoperfusion occur. a. ischemic stroke b. hemorrhagic stroke c. hypertensive stroke

a. ischemic stroke

Penumbra region: a. salvable tissue b. dead tissue c. area of language production

a. salvable tissue

It is important in the assessment of stroke to determine ____. a. when symptoms started b. degree of muscle weakness c. severity of headache

a. when symptoms started

Internal carotid arteries: supply blood to ____.

anterior brain

Frozen plasma and vitamin K given if hemorrhagic stroke is caused by ___.

anticoagulant

A patient suffering from a hemorrhagic stroke may be given which prophylatic medication?

anticonvulsant medication

Main presenting symptom of ischemic stroke: a. exploding headache b. hemiparesis c. vomiting

b. hemiparesis

Interruption of blood flow to part of the brain From blocked or ruptured artery a. Arteriovenous Malformation b. Cerebral aneurysm c. Cerebrovascular accident

c. Cerebrovascular accident

_______: the inability to speak clearly a. Aphasia b. Agnosia c. Dysarthria d. Dysphagia

c. Dysarthria

______: weakness one side of the body a. Dyspraxia b. Hemiplegia c. Hemiparesis

c. Hemiparesis

S/S of Right-sided brain damage (select all that apply): a. Memory deficits b. Aware of deficits c. Left-sided neglect d. Slow, cautious behavior e. Aphasia

c. Left-sided neglect

S/S of Left-sided brain damage (select all that apply): a. Left-sided paralysis b. Spatial-perceptual deficits c. Right-sided paralysis d. Aphasia e. Slow, cautious behavior

c. Right-sided paralysis d. Aphasia e. Slow, cautious behavior

One of the biggest modifiable risk factor in development of ischemic stroke is __. a. diabetes b. obesity c. atrial fibrillation

c. atrial fibrillation

tPA side effect a. vomiting b. clotting c. bleeding

c. bleeding

Hemorrhagic stroke results in (select all that apply): a. Increase in WBC count b. Pneumonia c. DVT d. Compression of brain contents e. Spasm of adjacent blood vessels

d. Compression of brain contents e. Spasm of adjacent blood vessels

_____: swallowing difficulty a. Aphasia b. Agnosia c. Dysarthria d. Dysphagia

d. Dysphagia

Types of ischemic stroke (select all that apply): a. Arteriovenous malformation b. Intracerebral hemorrhage c. Subarachnoid hemorrhage d. Other- migraines e. Cerebral aneurysm

d. Other- migraines

Non-contrast CT scan can help to ___. a. determine type of stroke b. course of treatment c. dissolve clot d. a and b only

d. a and b only

Damage to Broca's area results in:

expressive aphasia

If you're on an anticoagulant, the prothrombin time is expressed as an:

international normalized ratio (INR)

Strokes can be divided into two major categories:

ischemic and hemorrhagic

Prothrombin time greater than 13 seconds means that:

it takes blood longer than usual to clot

Ischemic strokes have a ____ mortality rate compared to hemorrhagic stroke. Although, the morbidity rate is much higher.

lower

Functional Independence Measure (FIM™) instrument is a basic indicator of

patient disability.

Vertebral arteries: supply blood to ____.

posterior brain

Damage to Wernicke's area results in:

receptive aphasia

tPA is ___ based.

weight

Goal: Give tPA _______ of arriving to the ED

within 60 minutes

Eligibility Criteria for tPA Administration Platelet count

≥ 100,000/mm3

Diagnostic tests used for TIA and stroke (select all that apply): a. 12 lead ECG b. non-contrast CT scan c. Biopsy d. transcranial doppler flow studies e. carotid ultrasound/angiography

a. 12 lead ECG b. non-contrast CT scan d. transcranial doppler flow studies e. carotid ultrasound/angiography

Non-contrast CT within _____. a. 25 minutes b. 1 hour c. 3 to 4 hours

a. 25 minutes

_______: a defect in the use of language; speech, reading, writing, or word comprehension a. Aphasia b. Agnosia c. Dysarthria d. Dysphagia

a. Aphasia

Symptoms of ischemic stroke depend on the ___. a. location and size of the affected area b. baseline vital signs c. neurological status

a. location and size of the affected area

Assessment of stroke: a. Glasgow Coma Scale b. NIHSS assessment tool c. FIM

b. NIHSS assessment tool

S/S of Hemorrhagic stroke (select all that apply): a. capillary refill < 3 seconds b. visual disturbances c. focal seizure d. neck stiffness e. joint swelling

b. visual disturbances c. focal seizure d. neck stiffness

Eligibility Criteria for tPA Administration No gastrointestinal or urinary ______ within 21 days.

bleeding

Prothrombin time less than 10 seconds means that:

blood clots more quickly than normal

A client is experiencing dysphagia following a stroke. Which measure may be taken by the nurse to ensure that the client's diet allows for easy swallowing? a. Instruct the client to lie on the bed when eating. b. Offer liquids frequently and in large quantities. c. Help the client sit upright when eating and feed slowly. d. Allow optimum physical activity before meals to expedite digestion.

c. Help the client sit upright when eating and feed slowly.

A diagnostic test has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include honey thickened liquids. Which of the following is the priority nursing diagnosis for this client? a. Risk for Fluid Volume Deficit b. Risk for Electrolyte Imbalance c. Impaired Swallowing d. Altered Nutrition: Less Than Body Requirements

c. Impaired Swallowing

Main diagnostic test to determine type of stroke: a. IV contrast CT scan b. MRI c. Non-contrast CT scan

c. Non-contrast CT scan

NIHSS Score: 42 a. normal b. moderate c. severe

c. severe

Fourth leading cause of death in the U.S Most disabling of all neurologic diseases a. HTN b. MI c. stroke

c. stroke

Acute Phase of Ischemic Stroke Every hour a. first 2 hours b. next 6 hours c. until 24 hours/after tx

c. until 24 hours/after tx

After a stroke, a client is admitted to the facility. The client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g. Which nursing intervention is a priority for this client? a. Checking stools for occult blood b. Performing range-of-motion (ROM) exercises on the left side c. Keeping skin clean and dry d. Elevating the head of the bed to 30 degrees

d. Elevating the head of the bed to 30 degrees Explanation: Because the client's gag reflex is absent, elevating the head of the bed to 30 degrees helps minimize the client's risk of aspiration.

NIHSS Scores: 0 a. normal b. moderate c. severe

a. normal

TIA usually lasts: a. more than 2 hours b. less than hour c. on and off for 24 hours

b. less than hour

Acute Phase of Ischemic Stroke VS q 30 for ____. a. first 2 hours b. next 6 hours c. until 24 hours/after tx

b. next 6 hours

Eligibility Criteria for tPA Administration Cannot be: a. over 50 b. pregnant c. at a normal glucose level

b. pregnant

S/S of Hemorrhagic stroke (select all that apply): a. stomach cramps b. severe headache c. urinary urgency d. vomiting e. sudden change in LOC

b. severe headache d. vomiting e. sudden change in LOC

Most common type of ischemic stroke a. large artery thrombotic stroke b. small penetrating artery thrombotic stroke c. cardiogenic embolic strokes

b. small penetrating artery thrombotic stroke

Interventions for modifiable risk factors (select all that apply): a. high-carb diet b. treat periodontal diseases c. high-sodium diet d. anticoagulation for dysrhythmias and valve disease e. smoking cessation

b. treat periodontal diseases c. d. anticoagulation for dysrhythmias and valve disease e. smoking cessation

Prevent or minimize bleeding is a major goal for: a. ischemic stroke b. TIA c. hemorrhagic stroke

c. hemorrhagic stroke

A client admitted to the emergency department is being evaluated for the possibility of a stroke. Which assessment finding would lead the nurse to suspect that the client is experiencing a hemorrhagic stroke? a. severe exploding headache b. left-sided weakness c. slurred speech d. difficulty finding appropriate words

a. severe exploding headache

Hemorrhagic stroke is due to: a. spontaneous rupture of a cerebral vessel b. occluded artery c. atrial fibrillation

a. spontaneous rupture of a cerebral vessel

Medical Management of Hemorrhagic stroke (select all that apply): a. supplement oxygen b. capillary refill < 3 seconds c. monitor for seizures d. dim lighting e. compression stockings

a. supplement oxygen c. monitor for seizures d. dim lighting e. compression stockings

Maintain patent airway and prevent aspiration is a major goal for: a. MI b. ischemic stroke c. TIA

b. ischemic stroke

S/S of ischemic stroke (select all that apply): a. exploding headache b. vomiting c. hemiparesis d. visual disturbances e. aphasia

c. hemiparesis d. visual disturbances e. aphasia

Types of hemorrhagic stroke (select all that apply): a. Arteriovenous malformation b. Cerebral aneurysm c. Coagulopathies d. Illicit drug use e. Cryptogenic

a. Arteriovenous malformation b. Cerebral aneurysm

Which of the following, if left untreated, can lead to an ischemic stroke? a. Atrial fibrillation b. Cerebral aneurysm c. Arteriovenous malformation (AVM) d. Ruptured cerebral arteries

a. Atrial fibrillation

During assessment of cognitive impairment, post-stroke, the nurse documents that the patient was experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe? a. Frontal b. Occipital c. Parietal d. Temporal

a. Frontal

Interventions for Ischemic Stroke (select all that apply): a. Have patient sit upright to eat b. Prevent constipation c. High-fat diet d. High-sodium diet e. Use of thickened liquids or pureed diet

a. Have patient sit upright to eat b. Prevent constipation e. Use of thickened liquids or pureed diet

Acute Phase of Ischemic Stroke VS q 15 for: a. first 2 hours b. next 6 hours c. until 24 hours/after tx

a. first 2 hours

S/S of Increased ICP (select all that apply): a. headache b. alertness c. blurred vision d. increased energy e. vomiting

a. headache c. blurred vision e. vomiting

Approximately 13% of stroke cases. Extravasation of blood into the brain or subarachnoid space. a. ischemic stroke b. hemorrhagic stroke c. hypertensive stroke

b. hemorrhagic stroke

S/S of Increased ICP (select all that apply): a. alertness b. muscle weakness c. difficulty walking d. change in LOC e. oriented times 3

b. muscle weakness c. difficulty walking d. change in LOC

Types of ischemic stroke (select all that apply): a. Arteriovenous malformation b. Cerebral aneurysm c. Other- Coagulopathies d. Other- Illicit drug use e. Cryptogenic

c. Other- Coagulopathies d. Other- Illicit drug use e. Cryptogenic

Interventions for Ischemic Stroke (select all that apply): a. Supine position b. Bed rest c. Place pillow in axilla d. Encourage patient to exercise unaffected side e. Prone positioning

c. Place pillow in axilla d. Encourage patient to exercise unaffected side e. Prone positioning

Precursor to a stroke → "Warning of an impending stroke" Temporary neurologic deficit resulting from a temporary impairment of blood flow a. Arteriovenous Malformation b. Cerebral aneurysm c. Transient Ischemic Attack (TIA)

c. Transient Ischemic Attack (TIA)

A patient has left-sided facial drooping, slurred speech, and his left arm drifts downward. The sooner, the better regarding: a. administration of IV bolus normal saline b. administration of antiepileptic medication c. administration of non-contrast CT scan

c. administration of non-contrast CT scan

Medical Management of Hemorrhagic stroke (select all that apply): a. use of opioids b. use of incentive spirometer c. avoid coughing d. avoid sneezing e. avoid deep breathing

c. avoid coughing d. avoid sneezing e. avoid deep breathing

One of the biggest modifiable risk factor in development of hemorrhagic stroke is __. a. diabetes b. obesity c. hypertension

c. hypertension

S/S of Right-sided brain damage (select all that apply): a. Left-sided paralysis b. Spatial-perceptual deficits c. Right-sided paralysis d. Aphasia e. Slow, cautious behavior

a. Left-sided paralysis b. Spatial-perceptual deficits

Diagnostic tests used for TIA and stroke (select all that apply): a. MRI b. chorionic Villi Sampling c. xenon enhanced ct scan d. colonoscopy e. single photon emission

a. MRI c. xenon enhanced CT scan e. single photon emission

Types of hemorrhagic stroke (select all that apply): a. Small penetrating artery thrombosis b. Intracerebral hemorrhage c. Cardiogenic embolic d. Large artery thrombosis e. Subarachnoid hemorrhage

b. Intracerebral hemorrhage e. Subarachnoid hemorrhage

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention? a. Positioning the client to prevent airway obstruction b. Keeping the client in one position to decrease bleeding c. Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess d. Maintaining the client in a quiet environment

b. Keeping the client in one position to decrease bleeding

Medical Management of Hemorrhagic stroke (select all that apply): a. Increase activity as soon as possible b. Limit visitors c. Reduce stimulation d. Bright lighting e. Use of stool softeners

b. Limit visitors c. Reduce stimulation e. Use of stool softeners

Interventions for Ischemic Stroke (select all that apply): a. Strict bed rest b. Monitor for depression c. Decrease fluid intake d. Address sexual dysfunction e. Intermittent urinary catheterization

b. Monitor for depression d. Address sexual dysfunction e. Intermittent urinary catheterization

An INR lower than the recommended range means that your: a. blood clots more slowly than desired b. blood clots more quickly than desired

b. blood clots more quickly than desired

S/S of ischemic stroke (select all that apply): a. tinnitus b. change in mental status c. diarrhea d. difficulty walking e. confusion

b. change in mental status d. difficulty walking e. confusion

Interventions for Ischemic Stroke (select all that apply): a. lie flat b. bed rest c. passive or active ROM four or five times day d. place pillow between legs to turn laterally e. turn and position in correct alignment every 2 hours

c. passive or active ROM four or five times day d. place pillow between legs to turn laterally e. turn and position in correct alignment every 2 hours

A test to evaluate blood clotting. a. prothrombin time b. sodium levels c. potassium levels

a. prothrombin time

Risk factors for Hemorrhagic stroke (select all that apply): a. cancer b. active lifestyle c. aneursyms d. age < 30 e. AVM

a. cancer c. aneursyms e. AVM

S/S of Left-sided brain damage (select all that apply): a. Memory deficits b. Aware of deficits c. Quick, impulsive behavior d. Impaired judgement e. Short attention span

a. Memory deficits b. Aware of deficits

S/S of Right-sided brain damage (select all that apply): a. Memory deficits b. Aware of deficits c. Quick, impulsive behavior d. Impaired judgement e. Short attention span

a. Memory deficits c. Quick, impulsive behavior d. Impaired judgement e. Short attention span

Types of ischemic stroke (select all that apply): a. Small penetrating artery thrombosis b. Intracerebral hemorrhage c. Cardiogenic embolic d. Large artery thrombosis e. Subarachnoid hemorrhage

a. Small penetrating artery thrombosis c. Cardiogenic embolic d. Large artery thrombosis

S/S of Hemorrhagic stroke (select all that apply): a. anxiety b. hemiparesis c. joint swelling d. dizziness e. tinnitus

a. anxiety b. hemiparesis d. dizziness e. tinnitus

An INR higher than the recommended range means that your: a. blood clots more slowly than desired b. blood clots more quickly than desired

a. blood clots more slowly than desired

Assessment of stroke (select all that apply): a. breathing pattern b. presence of diarrhea c. rapid physical examination d. rapid neurological examination e. determine when symptoms started

a. breathing pattern c. rapid physical examination d. rapid neurological examination e. determine when symptoms started

A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the health care provider in the emergency department. Which is the origin of the client's symptoms? a. impaired cerebral circulation b. cardiac disease c. diabetes insipidus d. hypertension

a. impaired cerebral circulation

Atrial fibrillation increases the risk for ____ due to ____. a. ischemic stroke, blood stasis in atrium which leads to thrombus formation b. hemorrhagic stroke, blood stasis in atrium which leads to thrombus formation c. ischemic stroke, increased intravascular resistance

a. ischemic stroke, blood stasis in atrium which leads to thrombus formation

Pathophysiology of Ischemic Stroke Ischemia results in change from aerobic respiration to anaerobic respiration. Anaerobic respiration releases ___ which is very irritating to brain tissue. a. lactic acid b. CO2 c. blood

a. lactic acid

Pathophysiology of Hemorrhagic stroke a. microaneurysms in small arteries of the brain b. blocked artery due to atherosclerotic plaques c. peridontal disease

a. microaneurysms in small arteries of the brain

Characteristics of TIA (select all that apply): a. s/s last less than 1 hour b. guarantees that stroke will happen over time c. s/s last 3 to 4 hours d. precursor to stroke e. s/s similar to ischemic stroke

a. s/s last less than 1 hour d. precursor to stroke e. s/s similar to ischemic stroke

Assessment of stroke (select all that apply): a. test gag reflex b. test cough reflex c. presence of diarrhea d. presence of fluid retention e. assess airway patency

a. test gag reflex b. test cough reflex e. assess airway patency

_______: an inability to process sensory info and recognize things a. Aphasia b. Agnosia c. Dysarthria d. Dysphagia

b. Agnosia

A client is following up after a visit to the emergency department where testing indicated that the client had suffered a transient ischemic attack. What lifestyle changes would the nurse include in teaching to prevent further reoccurrence? Select all that apply. a. High-dose aspirin b. Blood pressure control c. Weight loss d. Physical activity limitations e. Smoking cessation

b. Blood pressure control c. Weight loss e. Smoking cessation

Interventions for Ischemic Stroke (select all that apply): a. Lift shoulder on affected side b. Chin tuck or swallowing method c. Canes and 4 prong walker d. Bed rest e. Assist patient out of bed as soon as possible

b. Chin tuck or swallowing method c. Canes and 4 prong walker e. Assist patient out of bed as soon as possible

Medical Management of Hemorrhagic stroke (select all that apply): a. Get them out of bed as soon as possible b. Craniotomy c. DVT prophylaxis d. Administration of anticonvulsant medication e. Walking and standing

b. Craniotomy c. DVT prophylaxis d. Administration of anticonvulsant medication

Medical Management of Hemorrhagic stroke (select all that apply): a. Supine positioning b. HOB 30 degrees c. Strict bed rest d. Passive ROM exercises e. Prone positioning

b. HOB 30 degrees c. Strict bed rest d. Passive ROM exercises

______: defined as paralysis of one side of the body a. Dyspraxia b. Hemiplegia c. Hemiparesis

b. Hemiplegia

The nurse is caring for a client diagnosed with a subarachnoid hemorrhage resulting from a leaking aneurysm. The client is awaiting surgery. Which nursing interventions would be appropriate for the nurse to implement? Select all that apply. a. Permit friends to visit often. b. Provide a dimly lit environment. c. Elevate the head of bed 30 degrees. d. Ambulate the client every hour. e. Administer docusate per order.

b. Provide a dimly lit environment. c. Elevate the head of bed 30 degrees. e. Administer docusate per order. Explanation: Cerebral aneurysm precautions are implemented for the patient with a diagnosis of aneurysm to provide a nonstimulating environment, prevent increases in intracranial pressure (ICP), and prevent further bleeding. The patient is placed on immediate and absolute bed rest*** in a quiet, nonstressful environment, because activity, pain, and anxiety elevate blood pressure, which increases the risk for bleeding. Visitors, except for family, are restricted. Dim lighting is helpful because photophobia (visual intolerance of light) is common. The head of the bed is elevated 15 to 30 degrees to promote venous drainage and decrease ICP. No enemas are permitted, but stool softeners (Colace) and mild laxatives are prescribed. Both prevent constipation, which would cause an increase in ICP, as would enemas.

Risk factors for Hemorrhagic stroke (select all that apply): a. on anticonvulsants b. diabetes c. on anticoagulants d. gets atleast 150 minutes of exercise e. smoking

b. diabetes c. on anticoagulants e. smoking

A nurse is reading a journal article about stroke and the underlying causes associated with this condition. The nurse demonstrates understanding of the information when identifying which subtype of stroke as being due to atrial fibrillation? a. large-artery thrombotic b. small, penetrating artery thrombotic c. cardio embolic d. cryptogenic

c. cardio embolic