Stroke Part 2
In order for tissue plasminogen activator (tPa) to be most effective in the treatment of stroke, it must be adminitered:
3 hours after the onset of stroke symptoms
Which client would the nurse identify as being most at risk for experiencing a CVA?
A 55-year-old African American Male
Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke?
A blood pressure of 220/120 mmHg
Which patients are NOT a candidate for tissue plasminogen activator (tPa) for the treatment of stroke? (SATA)
A patient whose blood pressure is 200/110 A patient who received Heparin 24 hours ago
Your patient has expressive aphasia. Select all the ways to effectively communicate with this patient? (SATA)
Ask question that require a simple response Use a communication board
During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to control the client's
Blood pressure
You are assisting a patient who has right side hemiparesis and dysphagia with eating. It is important to:
Check for pouching of food in the right cheek
The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge?
Oral anticoagulant medication
Regular oral hygiene is an essential intervention for the client who has had a stroke. Which of the following nursing measures is inappropriate when providing oral hygiene.
Placing the client on the back with a small pillow under the head
What is a priority nursing assessment in the first 24 hours post admission of the client with thrombotic stroke?
Pupil size and pupillary response
A patient has experienced right side brain damage. You note the patient is experiencing neglect syndrome. What nursing intervention will you include in the patient's plan of care?
Remind the patient to use and touch both sides of the body daily
A patient who has hemianopia is at risk for injury. What can you educate the patient to perform regularly to prevent injury?
Scanning the room from side to side frequently
A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which of the following should be the priority nursing intervention?
Schedule for a STAT computer tomography (CT) scan of the head
You receive a patient who is suspected of experiencing a stroke from EMS. You conduct a stroke assessment with the NIH Stroke Scale. The patient scores a 40. According to the scale, the result is:
Severe stroke symptoms
The nurse and unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene?
The assistant places her hand under the client's right axilla to help him/her move up in bed.
A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. Which is the priority nursing assessment?
Time of onset of current stroke
What is the expected outcome of a thrombolytic drug therapy?
Dissolved emboli
