Stroke
11. The nurse identifies the nursing diagnosis of impaired verbal communication for a patient with expressive aphasia. An appropriate nursing intervention to help the patient communicate is to 1. ask simple questions that can be answered with "yes" or "no." 2. develop a list of simple words that she can read and practice reciting. 3. have her practice facial and tongue exercises to improve motor control necessary for speech. 4. prevent embarrassing her by changing the subject if she does not respond in a timely manner.
Answer: 1
16. The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to inability to feed self for a patient with right-sided hemiplegia. An appropriate nursing intervention to help improve the patient's nutrition is to 1. assist the patient to eat with her left hand. 2. provide a pureed diet that is easy for the patient to swallow. 3. stroke the patient's throat while feeding her to stimulate swallowing of food. 4. provide a wide variety of food choices on the meal tray to stimulate her appetite.
Answer: 1
16. The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to inability to feed self for a patient with right-sided hemiplegia. An appropriate nursing intervention is to a. assist the patient to eat with the left hand. b. provide oral care before and after meals. c. teach the patient the "chin-tuck" technique. d. provide a wide variety of food choices.
Correct Answer: A Rationale: Because the nursing diagnosis indicates that the patient's imbalanced nutrition is related to the right-sided hemiplegia, the appropriate interventions will focus on teaching the patient to use the left hand for self-feeding. The other interventions are appropriate for patients with other etiologies for the imbalanced nutrition.
3. The nurse expects that management of the patient who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects will include 1. oral administration of ticlopidine (Ticlid). 2. heparin via continuous intravenous infusion. 3. prophylactic clipping of cerebral aneurysms. 4. therapy with tissue plasminogen activator (TPA).
Answer: 1
1. The daughter of a patient admitted unconscious to the emergency room with a possible stroke reports her mother has a history of hypertension that she does not manage well. She has been using estrogen replacement therapy for the past 6 years, and estrogen and her antihypertensive medication are the only drugs she uses. Her only activity is managing her home, and she appears overweight. The finding that the nurse recognizes as the most significant risk factor for a stroke in the patient is 1. obesity. 2. hypertension. 3. sedentary lifestyle. 4. estrogen replacement therapy.
Answer: 2
13. A patient has a stroke affecting the right hemisphere of the brain. Based on knowledge of the effects of right brain damage, the nurse establishes a nursing diagnosis of 1. impaired physical mobility related to right hemiplegia. 2. risk for injury related to denial of deficits and impulsiveness. 3. impaired verbal communication related to speech-language deficits. 4. ineffective coping related to depression and distress about disability.
Answer: 2
17. After 3 days, a patient with an ischemic stroke has stable symptoms and she is taught to balance herself sitting on the edge of the bed. To teach the patient to transfer from the bed to the wheelchair, the nurse 1. places the wheelchair next to the bed on the patient's affected side. 2. places the wheelchair parallel to the bed on the patient's unaffected side. 3. places the wheelchair directly in front of the patient while she is sitting on the side of the bed. 4. places a wheelchair with a removable arm against the bed where the patient is lying and has her slide from the bed to the chair.
Answer: 2
21. Following a stroke, a patient has urinary incontinence with an impaired impulse to void. A bladder retraining program for the patient should include 1. limiting fluid intake to 1000 ml/day to reduce urine volume. 2. assisting the patient onto the bed pan or the bedside commode every 2 hours. 3. performing intermittent catheterization after each voiding to check for residual urine. 4. inserting an indwelling catheter, clamping and draining the catheter every 4 hours to reestablish bladder tone.
Answer: 2
5. A patient with a stroke caused by thrombosis of the middle cerebral artery experiences right-sided paralysis of the upper and lower extremities and facial drooping on the right side. Based on the location of the patient's stroke, an additional assessment finding that the nurse would expect to be present is 1. apraxia. 2. aphasia. 3. atonic bladder. 4. central vision loss.
Answer: 2
12. Twenty-four hours after admission, a patient with a stroke has progressive development of neurologic deficits with increasing weakness and decreased level of consciousness. The primary goal of nursing management of the patient at this time is 1. protecting the skin from breakdown. 2. monitoring for changes in neurologic status. 3. maintaining the patient's respiratory function. 4. preventing joint contractures and muscle atrophy.
Answer: 3
14. A patient with homonymous hemianopia resulting from a stroke has a nursing diagnosis of disturbed sensory perception related to hemianopia. An appropriate nursing intervention that will help the patient learn to compensate for the deficit during the rehabilitation period is to 1. apply an eye patch to the affected eye. 2. approach the patient on the unaffected side. 3. place objects necessary for activities of daily living on the affected side. 4. teach the patient to exercise the eye muscles with full range of motion at least twice a day.
Answer: 3
20. A patient has right-sided paresis and aphasia as a result of a stroke but is attempting to use his left hand for feeding and other activities. When his wife visits, she insists on doing everything for him. A nursing diagnosis that is most appropriate in this situation is 1. situational low self-esteem related to increasing dependence on others. 2. interrupted family processes related to effects of illness of a family member. 3. disabled family coping related to inadequate understanding by primary person. 4. risk for ineffective therapeutic regimen management related to functional and communication limitations.
Answer: 3
22. A 72-year-old man is being discharged home following a stroke. He is able to walk with assistance but needs help with hygiene, dressing, and eating. The patient's 70-year-old wife has received instruction and practice in necessary areas of care. A statement by the patient's wife indicating to the nurse that the outcomes for discharge planning have been met includes 1. "I can handle all of my husband's needs with the instruction provided." 2. "I have arranged for a home health aide to provide all the care my husband will need." 3. "I can provide the care my husband needs if I use the support and resources available in the community." 4. "Because my husband will have continuous improvement in his condition, I won't need outside assistance in his care for very long."
Answer: 3
4. When a patient is hospitalized with a possible stroke, the nurse recognizes that the stroke most likely resulted from a subarachnoid hemorrhage when the patient's family reports that the patient 1. has a history of atrial fibrillation. 2. was unable to be aroused in the morning. 3. had been complaining of a headache before losing consciousness. 4. has had several brief episodes of mental confusion and right arm and leg weakness.
Answer: 3
7. The physician prescribes clopidogrel (Plavix) for a patient with cerebral atherosclerosis. The nurse teaches the patient that an expected outcome of this drug includes 1. regulation of his blood pressure. 2. breakdown of clots that have formed in his cerebral arteries. 3. prevention of platelet clumps around atherosclerotic plaques. 4. healing of sites where blood is leaking out of his cerebral arteries.
Answer: 3
8. The physician recommends a carotid endarterectomy for a patient with carotid atherosclerosis and a history of transient ischemic attacks. The patient asks the nurse whether this procedure involves brain surgery. In responding to the patient, the nurse includes the information that 1. an endarterectomy involves brain surgery because plaques in arteries at the base of the brain are removed. 2. this surgery involves resection of a diseased portion of the artery in the brain and replacing it with a synthetic graft. 3. a carotid endarterectomy involves removal of plaques in an artery in the neck and does not involve surgery in the brain. 4. in this surgery a burr hole is drilled in the skull to connect an artery outside the skull to one inside the brain, bypassing a blockage.
Answer: 3
9. On initial assessment of a patient hospitalized following a stroke, the nurse finds the patient's blood pressure to be 180/90. The nurse anticipates that 1. IV fluids will be withheld until the blood pressure is within normal range. 2. unless the blood pressure is lowered, the patient is at risk for another stroke. 3. IV fluids will be administered to promote hydration to maintain cerebral perfusion. 4. IV antihypertensive agents will be administered to maintain a mean arterial pressure (MAP) of 140 mm Hg.
Answer: 3
10. A 68-year-old man has had several transient ischemic attacks with temporary hemiparesis and dysarthria that have lasted up to an hour. The nurse encourages the patient to seek immediate medical assistance for any symptoms that last longer than an hour, explaining that permanent disability from a stroke may be reduced if therapy is initiated within 3 hours with the use of 1. intravenous heparin. 2. transluminal angioplasty. 3. a surgical endarterectomy. 4. tissue plasminogen activator (TPA).
Answer: 4
15. During the acute phase of a patient with an ischemic stroke, the nurse monitors the patient's neurologic status closely with the knowledge that following a stroke, increased intracranial pressure from cerebral edema is most likely to peak in 1. 12 hours. 2. 24 hours. 3. 48 hours. 4. 72 hours.
Answer: 4
18. A 32-year-old patient has a stroke resulting from a ruptured aneurysm with a subarachnoid hemorrhage. In planning initial care for the patient, the nurse recognizes a patient outcome appropriate for patients with ischemic strokes that would be contraindicated for this patient is 1. tolerates food and fluids without choking. 2. demonstrates ability to communicate needs. 3. performs active range of motion of the extremities. 4. transfers and ambulates at maximal level of activity.
Answer: 4
19. When initiating oral feedings for a patient with a stroke, the nurse determines that the patient has an intact gag reflex and then 1. assesses the patient's ability to move the tongue. 2. offers semisolid food that is easiest for the patient to swallow. 3. suctions the patient's oral cavity to prevent aspiration of secretions. 4. places the patient in a high-Fowler's position with the head flexed forward.
Answer: 4
2. A patient is hospitalized with a stroke manifested by hemiplegia and impaired speech. When obtaining a health history from the patient's family, the nurse recognizes that the effects of the stroke are most likely to be complicated by the patient's history of 1. hypertension. 2. diabetes mellitus. 3. moderate alcohol consumption. 4. chronic obstructive pulmonary disease.
Answer: 4
6. A patient has an occlusion of the left posterior cerebral artery. The nurse recognizes that manifestations most likely to occur indicate damage to the 1. cerebellum. 2. frontal lobe. 3. parietal lobe. 4. occipital and inferior temporal lobes.
Answer: 4
5. A patient with a stroke experiences right-sided arm and leg paralysis and facial drooping on the right side. When obtaining admission assessment data about the patient's clinical manifestations, it is most important the nurse assess the patient's a. ability to follow commands. b. visual fields. c. right-sided reflexes. d. emotional state.
Correct Answer: A Rationale: Because the patient with a left-sided brain stroke may also have difficulty with comprehension and use of language, so it is important to obtain baseline data about the ability to follow commands. This will impact on patient safety and nursing care. The visual fields are not typically affected by a left-sided stroke. Information about reflexes and emotional state will be collected but is not as high a priority as information about language abilities.
11. The nurse identifies the nursing diagnosis of impaired verbal communication for a patient with expressive aphasia. An appropriate nursing intervention to help the patient communicate is to a. ask simple questions that the patient can answer with "yes" or "no." b. develop a list of words that the patient can read and practice reciting. c. have the patient practice facial and tongue exercises to improve motor control necessary for speech. d. prevent embarrassing the patient by changing the subject if the patient does not respond in a timely manner.
Correct Answer: A Rationale: Communication will be facilitated and less frustrating to the patient when questions that require a "yes" or "no" response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to respond.
2. A patient with right-sided weakness that started 1 hour ago is admitted to the emergency department and all these diagnostic tests are ordered. Which order should the nurse act on first? a. Noncontrast computed tomography (CT) scan b. Chest radiograph c. Complete blood count (CBC) d. Electrocardiogram (ECG)
Correct Answer: A Rationale: Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 3 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the smaller the area of brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.
22. A 72-year-old is being discharged home following a stroke. The patient is able to walk with assistance but needs help with hygiene, dressing, and eating. Which statement by the patient's wife indicates that discharge planning goals have been met? a. "I can provide the care my husband needs if I use the support and resources available in the community." b. "Because my husband will have continuous improvement in his condition, I won't need outside assistance in his care for very long." c. "I can handle all of my husband's needs thanks to the instructions you've given me." d. "I have arranged for a home health aide to provide all the care my husband will need."
Correct Answer: A Rationale: The statement that community resources will be used indicates a realistic outcome. The patient is unlikely to continue to improve to the point of needing no assistance. The wife is likely to be overwhelmed by the patient's needs if she attempts to manage without assistance. There is no indication that the patient will need a home health aide to meet all of his care needs.
27. A patient with sudden-onset right-sided weakness has a CT scan and is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? a. The patient has atrial fibrillation and takes warfarin (Coumadin). b. The patient takes a diuretic because of a history of hypertension. c. The patient's blood pressure is 144/90 mm Hg. d. The patient's speech is difficult to understand.
Correct Answer: A Rationale: The use of warfarin will have contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patient's care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated.
6. The nurse on the medical unit receives a verbal report from the emergency department nurse that a patient has an occlusion of the left posterior cerebral artery. When admitting the patient to the medical floor, the nurse will anticipate that the patient may have a. visual deficits. b. dysphasia. c. confusion. d. poor judgment.
Correct Answer: A Rationale: Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with middle cerebral artery involvement. Cognitive deficits and changes in judgment are more typical of anterior cerebral artery occlusion.
21. Several weeks after a stroke, a patient has urinary incontinence resulting from an impaired awareness of bladder fullness. A bladder retraining program for the patient should include a. limiting fluid intake to 1000 ml daily to reduce urine volume. b. assisting the patient onto the bedside commode every 2 hours. c. performing intermittent catheterization after each voiding to check for residual urine. d. using an external "condom" catheter to protect the skin and prevent embarrassment.
Correct Answer: B Rationale: Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full bladder. A 1000-ml fluid intake is too restricted and will lead to dehydration. Intermittent catheterization and use of a condom catheter are appropriate in the acute phase of stroke but should not be considered solutions for long-term management because of the risks for urinary tract infection (UTI) and skin breakdown.
24. A patient is admitted to the hospital with dysphasia and right-sided weakness that resolves in a few hours. The nurse will anticipate teaching the patient about a. alteplase (tPA). b. aspirin (Ecotrin). c. warfarin (Coumadin). d. nimodipine (Nimotop).
Correct Answer: B Rationale: Following a TIA, patients typically are started on medications such as aspirin to inhibit platelet function and decrease stroke risk. tPA is used for acute ischemic stroke. Coumadin is usually used for patients with atrial fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage.
1. The nurse obtains all of the following information about a 65-year-old patient in the clinic. When developing a plan to decrease stroke risk, which risk factor is most important for the nurse to address? a. The patient smokes a pack of cigarettes daily. b. The patient's blood pressure (BP) is chronically between 150/80 to 170/90 mm Hg. c. The patient works at a desk and relaxes by watching television. d. The patient is 25 pounds above the ideal weight.
Correct Answer: B Rationale: Hypertension is the most important modifiable risk factor. Smoking, physical inactivity, and obesity all contribute to stroke risk but not so much as hypertension.
8. The health care provider recommends a carotid endarterectomy for a patient with carotid atherosclerosis and a history of transient ischemic attacks (TIA). The patient asks the nurse to describe the procedure. Which response by the nurse is appropriate? a. "The diseased portion of the artery in the brain is removed and replaced with a synthetic graft." b. "The carotid endarterectomy involves surgical removal of plaque from an artery in the neck." c. "A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque." d. "A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed."
Correct Answer: B Rationale: In a carotid endarterectomy, the carotid artery is incised and the plaque is removed. The response beginning, "The diseased portion of the artery in the brain is removed" describes an arterial graft procedure. The answer beginning, "A catheter with a deflated balloon is positioned at the narrow area" describes an angioplasty. The final response (beginning, "A wire is threaded through the artery") describes the Merci procedure.
17. The nurse is assisting the patient who is recovering from an acute stroke and has right-side hemiplegia to transfer from the bed to the wheelchair. Which action by the nurse is appropriate? a. Positioning the wheelchair next to the bed on the patient's right side b. Placing the wheelchair parallel to the bed on the patient's left side c. Setting the wheelchair directly in front of the patient, who is sitting on the side of the bed d. Moving the wheelchair a few steps from the bed and having the patient walk to the chair
Correct Answer: B Rationale: Placing the wheelchair on the patient's left side will allow the patient to use the left hand to grasp the left arm of the chair to transfer. If the chair is placed on the patient's right side or in front of the patient, it will be awkward to use the strong arm, and the patient will be at increased risk for a fall. Because the patient has hemiplegia, it is not appropriate to place the chair where the patient will need to walk to it.
26. A patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? a. Obtain the Glasgow Coma Scale score. b. Check the respiratory rate. c. Monitor the blood pressure. d. Send the patient for a CT scan.
Correct Answer: B Rationale: The initial nursing action should be to assess the airway and take any needed actions to assure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, circulation) are completed.
15. A patient who has had a subarachnoid hemorrhage is being cared for in the intensive care unit. Which information about the patient is most important to communicate to the health care provider? a. The patient complains of an ongoing severe headache. b. The patient's blood pressure is 90/50 mm Hg. c. The cerebrospinal fluid (CFS) report shows red blood cells (RBCs). d. The patient complains about having a stiff neck.
Correct Answer: B Rationale: To prevent cerebral vasospasm and maintain cerebral perfusion, blood pressure needs to be maintained at a high level after a subarachnoid hemorrhage. A low or drop in BP indicates a need to administer fluids and/or vasopressors to increase the BP An ongoing headache, RBCs in the CSF, and a stiff neck are all typical clinical manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the health care provider.
4. Aspirin is ordered for a patient who is admitted with a possible stroke. Which information obtained during the admission assessment indicates that the nurse should consult with the health care provider before giving the aspirin? a. The patient has atrial fibrillation. b. The patient has dysphasia. c. The patient states, "I suddenly developed a terrible headache." d. The patient has a history of brief episodes of right hemiplegia.
Correct Answer: C Rationale: A sudden-onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack (TIA) are not contraindications to aspirin use, so the nurse can administer the aspirin.
23. A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering the medications, the patient says, "I don't need the aspirin today. I don't have any aches or pains." Which action should the nurse take? a. Document that the aspirin was refused by the patient. b. Call the health care provider to clarify the medication order. c. Explain that the aspirin is ordered to decrease stroke risk. d. Tell the patient that the aspirin is used to prevent aches.
Correct Answer: C Rationale: Aspirin is ordered to prevent stroke in patients who have experienced TIAs. Documentation of the patient's refusal to take the medication is an inadequate response by the nurse. There is no need to clarify the order with the health care provider. The aspirin is not ordered to prevent aches and pains.
14. A patient with homonymous hemianopsia resulting from a stroke has a nursing diagnosis of disturbed sensory perception related to hemianopsia. To help the patient learn to compensate for the deficit during the rehabilitation period, the nurse should a. apply an eye patch to the affected eye. b. approach the patient on the unaffected side. c. place objects necessary for activities of daily living on the patient's affected side. d. have the patient use the eye muscles to move the eyes through the entire visual field.
Correct Answer: C Rationale: During the rehabilitation period, placing objects on the affected side will encourage the patient to use the scanning technique to visualize the affected side. Because homonymous hemianopsia affects half the visual field in each eye, use of an eye patch is not appropriate. Approaching the patient on the affected side is appropriate during the acute period but does not help the patient learn skills needed to compensate for the visual defect. The problem is with the visual field, not with the eye muscles, so practice moving the eyes through the visual field will not be effective.
28. A patient with a left-sided brain stroke suddenly bursts into tears when family members visit. The nurse should a. explain to the family that depression is normal following a stroke. b. have the family members leave the patient alone for a few minutes. c. teach the family that emotional outbursts are common after strokes. d. use a calm voice to ask the patient to stop the crying behavior.
Correct Answer: C Rationale: Patients who have left-sided brain stroke are prone to emotional outbursts, which are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient's outburst suggests that depression is not the major cause of the behavior. The family should stay with the patient. The crying is not within the patient's control and asking the patient to stop will lead to embarrassment.
7. The health care provider prescribes clopidogrel (Plavix) for a patient with cerebral atherosclerosis. When teaching about the new medication, the nurse will tell the patient a. that Plavix will reduce cerebral artery plaque formation. b. to monitor and record the blood pressure daily. c. to call the health care provider if stools are tarry. d. that Plavix will dissolve clots in the cerebral arteries.
Correct Answer: C Rationale: Plavix inhibits platelet function and increases the risk for gastrointestinal bleeding, so patients should be advised to notify the health care provider about any signs of bleeding. The medication does not lower blood pressure, decrease plaque formation, or dissolve clots.
12. A patient with a stroke has progressive development of neurologic deficits with increasing weakness and decreased level of consciousness (LOC). The priority nursing diagnosis for the patient is a. risk for impaired skin integrity related to immobility. b. disturbed sensory perception related to brain injury. c. risk for aspiration related to inability to protect airway. d. impaired physical mobility related to weakness.
Correct Answer: C Rationale: Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other diagnoses are also appropriate, but interventions to prevent aspiration are the priority at this time
13. A patient has a stroke affecting the right hemisphere of the brain. Based on knowledge of the effects of right brain damage, the nurse establishes a nursing diagnosis of a. impaired physical mobility related to right hemiplegia. b. impaired verbal communication related to speech-language deficits. c. risk for injury related to denial of deficits and impulsiveness. d. ineffective coping related to depression and distress about disability.
Correct Answer: C Rationale: Right-sided brain damage typically causes denial of any deficits and poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability.
25. The nurse is caring for a patient with carotid artery narrowing who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse? a. The pulse rate is 104 beats/min. b. There are fine crackles at the lung bases. c. The patient has difficulty talking. d. The blood pressure is 142/88 mm Hg.
Correct Answer: C Rationale: Small emboli can occur during carotid artery angioplasty and stenting, and the aphasia indicates a possible stroke during the procedure. Slightly elevated pulse rate and blood pressure are not unusual as a result of anxiety associated with the procedure. Fine crackles at the lung bases may indicate atelectasis caused by immobility during the procedure; the nurse should have the patient take some deep breaths.
20. A patient has right-sided weakness and aphasia as a result of a stroke but is attempting to use the left hand for feeding and other activities. The patient's wife insists on feeding and dressing him, telling the nurse, "I just don't like to see him struggle." A nursing diagnosis that is most appropriate in this situation is a. situational low self-esteem related to increasing dependence on others. b. interrupted family processes related to effects of illness of a family member. c. disabled family coping related to inadequate understanding by patient's spouse. d. ineffective therapeutic regimen management related to hemiplegia and aphasia.
Correct Answer: C Rationale: The information supports the diagnosis of disabled family coping because the wife does not understand the rehabilitation program. There are no data supporting low self-esteem, and the patient is attempting independence. The data do not support an interruption in family processes because this may be a typical pattern for the couple. The patient's attempts to use the left hand indicate that he is managing the therapeutic regimen appropriately.
9. On initial assessment of a patient hospitalized following a stroke, the nurse finds the patient's blood pressure to be 180/90 mm Hg. Which of the following orders by the health care provider should the nurse question? a. Infuse normal saline at 75 ml/hr. b. Keep head of bed elevated at least 30 degrees. c. Administer tissue plasminogen activator (tPA) per protocol. d. Titrate labetolol (Normodyne) drip to keep BP less than 140/90 mm Hg.
Correct Answer: D Rationale: Since elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if MAP is >130 mm Hg or systolic pressure is >220 mm Hg. Fluid intake should be 1500 to 2000 ml daily to maintain cerebral blood flow. The head of the bed should be elevated to at least 30 degrees unless the patient has symptoms of poor tissue perfusion. tPA may be administered if the patient meets the other criteria for tPA use.
19. A patient who has had a stroke has a new order to attempt oral feedings. The nurse should assess the gag reflex and then a. offer the patient a sip of juice. b. order a varied pureed diet. c. assess the patient's appetite. d. assist the patient into a chair.
Correct Answer: D Rationale: The patient should be as upright as possible before attempting feeding to make swallowing easier and decrease aspiration risk. To assess swallowing ability, the nurse should initially offer water or ice to the patient. Pureed diets are not recommended because the texture is too smooth. The patient may have a poor appetite, but the oral feeding should be attempted regardless.
18. A 32-year-old patient has a stroke resulting from a ruptured aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan? a. Encouraging patient to cough and deep breath every 4 hours b. Inserting an oropharyngeal airway to prevent airway obstruction c. Assisting to dangle on edge of bed and assess for dizziness d. Applying intermittent pneumatic compression stockings
Correct Answer: D Rationale: The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for deep vein thrombosis (DVT). Activities (such as coughing and sitting up) that might increase intracranial pressure (ICP) or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate.
10. A patient with a history of several transient ischemic attacks (TIAs) arrives in the emergency room with hemiparesis and dysarthria that started 2 hours previously. The nurse anticipates the need to prepare the patient for a. intravenous heparin administration. b. transluminal angioplasty. c. surgical endarterectomy. d. tissue plasminogen activator (tPA) infusion.
Correct Answer: D Rationale: The patient's history and clinical manifestations suggest an acute ischemic stroke and a patient who is seen within 3 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy are not indicated for the patient who is having an acute ischemic stroke.
3. The nurse expects that management of the patient who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects will include a. heparin via continuous intravenous infusion. b. prophylactic clipping of cerebral aneurysms. c. therapy with tissue plasminogen activator (tPA). d. oral administration of ticlopidine (Ticlid).
Correct Answer: D Rationale: The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, but not for TIA.
