Honan, Chapter 47: Nursing Management: Patients With Cerebrovascular Disorders

Thrombolytic therapy should be initiated within what time frame of an ischemic stroke to achieve the best functional outcome?

3 hours

Which are contraindications for the administration of tissue plasminogen activator (t-PA)? Select all that apply.

Intracranial hemorrhage Major abdominal surgery within 10 days

The nurse is caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke does the nurse know this client has?

Ischemic

What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke?

Left visual field deficit

Which is the initial diagnostic test for a stroke?

Noncontrast computed tomography

The nurse has just received report on a client in the ED being transferred to the acute stroke unit with a diagnosis of a right hemispheric stroke. Which findings does the nurse understand is indicative of a right hemispheric stroke?

Spatial-perceptual deficits

When caring for a patient who has had a hemorrhagic stroke, close monitoring of vital signs and neurological status is imperative. What is the earliest sign of deterioration in a patient with a hemorrhagic stroke?

Alteration in level of consciousness (LOC)

Which of the following is the most common side effect of tissue plasminogen activator (tPA)?

Bleeding

A female patient who is recovering from a stroke has begun eating a minced and pureed diet after passing the speech pathologist's swallowing assessment. This morning, the nurse set up the patient with her breakfast tray and later noticed that the woman was swallowing her food well but dribbling small amounts of food out of affected side of her mouth. How should the nurse follow up this observation?

Cue the patient to the fact that she is dribbling food while commending her for eating.

A client is receiving an IV infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To confirm that this drug is producing its therapeutic effect, the nurse should consider which finding most significant?

Increased urine output

An emergency department nurse is interviewing a client who is presenting with signs of an ischemic stroke that began 2 hours ago. The client reports a history of a cholecystectomy 6 weeks ago and is taking digoxin, warfarin, and labetalol. What factor poses a threat to the client for thrombolytic therapy?

International normalized ratio greater than 2

A nurse is caring for a client with a cerebral aneurysm. Which nursing interventions would be most useful to the nurse to avoid bleeding in the brain? Select all that apply.

Report changes in neurologic status as soon as a worsening trend is identified. Maintain the head of the bed at 30 degrees. Avoid any activities that cause a Valsalva maneuver.

What nursing intervention is appropriate for a client with receptive aphasia?

Speak slowly and clearly.

Which of the following is the chief cause of intracerebral hemorrhage (ICH)?

Uncontrolled hypertension

A patient who just suffered a hemorrhagic stroke is brought to the emergency department by ambulance. What should be the nurse's primary assessment focus?

Cardiac and respiratory status

The provider diagnoses the patient as having had an ischemic stroke. The etiology of an ischemic stroke would include which of the following?

Cardiogenic emboli

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.

Weight loss Smoking cessation Blood pressure control

A client diagnosed with a stroke is ordered to receive warfarin. Later, the nurse learns that the warfarin is contraindicated and the order is canceled. The nurse knows that the best alternative medication to give is

aspirin.

A patient has been admitted to a unit at a primary stroke center after experiencing an ischemic stroke. The nurse on the unit is aware of the vital importance of rehabilitative efforts and knows that an active rehabilitation program should begin at what point?

As soon as the patient regains consciousness

A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to perform which action?

Form words that are understandable or comprehend spoken words

Which of the following, if left untreated, can lead to an ischemic stroke?

Atrial fibrillation

A client who complains of recurring headaches, accompanied by increased irritability, photophobia, and fatigue is asked to track the headache symptoms and occurrence on a calendar log. Which is the best nursing rationale for this action?

Migraines often coincide with menstrual cycle.

A nurse is instructing the spouse of a client who suffered a stroke about the use of eating devices the client will be using. During the teaching, the spouse starts to cry and states, "One minute he is laughing, and the next he's crying; I just don't understand what's wrong with him." Which statement is the best response by the nurse?

"Emotional lability is common after a stroke, and it usually improves with time."

A client is prescribed sumatriptan for the treatment of migraine headache. Which client statement would indicate a need for additional teaching from the nurse?

"I use this to prevent migraines." SUBMIT ANSWER

Disturbed by the high incidence and poor outcomes of stroke in the community, a public health nurse is planning a health promotion campaign that is specifically focused on stroke. Which of the following proposed outcomes would most directly address an identified public awareness need?

"Participants will state the most common signs and symptoms of stroke."

A client recently experienced a stroke with accompanying left-sided paralysis. His family voices concerns about how to best interact with him. They report the client doesn't seem aware of their presence when they approach him on his left side. What advice should the nurse give the family?

"The client is unaware of his left side. You should approach him on the right side."

If warfarin is contraindicated as a treatment for stroke, which medication is the best option?

Aspirin

Aneurysm rebleeding occurs most frequently during which time frame after the initial hemorrhage?

First 2 to 12 hours

A stroke victim is experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe?

Frontal

A client undergoes cerebral angiography for evaluation of a subarachnoid hemorrhage. Which findings indicate spasm or occlusion of a cerebral vessel by a clot?

Hemiplegia, seizures, and decreased level of consciousness

An emergency department (ED) nurse has administered an ordered bolus of tissue plasminogen activator (tPA) to a male patient who was diagnosed with stroke. During the administration of tPA, the nurse should prioritize assessments related to what problem?

Hemorrhage

A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question?

Heparin sodium

Which term will the nurse use when referring to blindness in the right or left half of the visual field in both eyes?

Homonymous hemianopsia

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?

Impaired Swallowing

A patient is brought to the emergency department with a possible stroke. What initial diagnostic test for a stroke, usually performed in the emergency department, would the nurse prepare the patient for?

Noncontrast computed tomogram

Which of the following is the initial diagnostic in suspected stroke?

Noncontrast computed tomography (CT)

A patient has had an ischemic stroke and has been admitted to the unit. The nurse knows the importance of the principles of body alignment and correct positioning to stroke victims. How should the nurse position the patient to prevent joint deformities?

Place a pillow in the axilla when there is limited external rotation.

A nurse is planning care for a client who experienced a stroke in the right hemisphere of his brain. What should the nurse do?

Provide close supervision because of the client's impulsiveness and poor judgment.

The nurse is caring for a client following an aneurysm coiling procedure. The nurse documents that the client is experiencing Korsakoff syndrome. Which set of symptoms characterizes Korsakoff syndrome?

Psychosis, disorientation, delirium, insomnia, and hallucinations

A client on your unit is scheduled to have intracranial surgery in the morning. Which nursing intervention helps to avoid intraoperative complications, reduce cerebral edema, and prevent postoperative vomiting?

Restrict fluids before surgery.

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are:

Severe headache and early change in level of consciousness

Which interventions would be recommended for a client with dysphagia? Select all that apply.

Test the gag reflex before offering food or fluids. Allow ample time to eat. Assist the client with meals.

When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke?

The day the patient has the stroke

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?

impaired cerebral circulation

When communicating with a client who has sensory (receptive) aphasia, the nurse should:

use short, simple sentences.