CH 67 Strokes

During a class on stroke, a junior nursing student asks what the clinical manifestations of stroke are. What would be the instructor's best answer? A. "Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation." B. "Clinical manifestations of a stroke generally include aphasia, one-sided flaccidity, and trouble swallowing." C. "Clinical manifestations of a stroke depend on how quickly the clot can be dissolved." D. "Clinical manifestations of a stroke are highly variable, depending on the cardiovascular health of the client."

"Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation."

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? A. "You seem upset, and it may be hard for you to focus on the teaching, I'll come back later." B. "You sound stressed; maybe using some stress management techniques will help." C. "This behavior is common in clients with stroke. Which does your spouse do more often? Laugh or cry?" D. "Emotional lability is common after a stroke, and it usually improves with time."

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

A patient presents to the emergency room with complaints of having an "exploding headache" for the last 2 hours. The patient is immediately seen by a triage nurse who suspects the patient is experiencing a stroke. Which of the following is a possible cause based on the characteristic symptom? A. Small artery thrombosis B. Large artery thrombosis C. Cerebral aneurysm D. Cardiogenic emboli

A cerebral aneurysm is a type of hemorrhagic stroke that is characterized by an exploding headache.

A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? A. Heparin B. dexamethasone C. methyldopa D. phenytoin

Heparin sodium *Administering heparin, an anticoagulant, could increase the bleeding associated with hemorrhagic stroke.

The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regimen, to maintain a healthy weight, and to adopt a reasonable exercise program. This advice is based on research data that shows the most important risk factor for stroke is: A. Dyslipidemia B. Hypertension C. Obesity D. Smoking

Hypertension

Which is a contraindication for the administration of tissue plasminogen activator (t-PA)? Ischemic stroke Intracranial hemorrhage Systolic blood pressure less than or equal to 185 mm Hg Age 18 years or older

Intracranial hemorrhage *Intracranial hemorrhage, neoplasm, and aneurysm are contraindications for t-PA

What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke? A. Aphasia B. Altered intellectual ability C. Left visual field deficit D. Slow, cautious behavior

Left visual field deficit * A left visual field deficit is a common clinical manifestation of a right hemispheric stroke.

A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings? A. Right-sided cerebrovascular accident (CVA) B. Completed Stroke C. Left-sided cerebrovascular accident (CVA) D. Transient ischemic attack (TIA)

Left-sided cerebrovascular accident (CVA) *When the infarct is on the left side of the brain, the symptoms are likely to be on the right, and the speech is more likely to be involved.

Which is the initial diagnostic test for a stroke? A. Electrocardiography B. Carotid Doppler C. Transcranial Doppler studies D. Noncontrast computed tomography

Noncontrast computed tomography *CT within 25 minutes

An emergency department nurse is awaiting the arrival of a client with signs of an ischemic stroke that began 1 hour ago, as reported by emergency medical personnel. The treatment window for thrombolytic therapy is which of the following? A. Six hours B. Three hours C. Two hours D. One hour

Rapid diagnosis of stroke and initiation of thrombolytic therapy (within 3 hours) in clients with ischemic stroke leads to a decrease in the size of the stroke and an overall improvement in functional outcome after 3 months.

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are: A. Confusion or change in mental status B. Severe headache and early change in level of consciousness C. Foot drop and external hip rotation D. Weakness on one side of the body and difficulty with speech

Severe headache and early change in level of consciousness *Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke

The nurse knows to give how many mg initially? When is the rest given?

Ten percent of the calculated dose is given as an IV bolus over 1 minute. The remaining dose (90%) is given IV over 1 hour via an infusion pump.

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 A. clopidogrel. B. aspirin. C. ticlopidine. D. dipyridamole.

aspirin

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? large-artery thrombotic cryptogenic cardio embolic small, penetrating artery thrombotic

cardio embolic *Cardio embolic strokes are associated with cardiac dysrhythmias, such as atrial fibrillation, but can also be associated with valvular heart disease or left ventricular thrombus.

When developing a care plan for a client who has recently suffered a stroke, a nurse includes the nursing diagnosis Risk for imbalanced body temperature. What is the rationale for this diagnosis? A. The stroke may have impacted the body's thermoregulation centers. B. A decreased body temperature will signal the need to cover the client. C. An elevated body temperature indicates infection. D. An elevated temperature indicates cerebellum malfunction.

A. The stroke may have impacted the body's thermoregulation centers. *The body's thermoregulation centers are located in the hypothalamus. A stroke may impair their functioning

After the patient has received tPA, the nurse knows to check vital signs every 30 minutes for 6 hours. Which of the following readings would require calling the provider? A. Respiration of 22 B. Heart rate of 100 C. Systolic pressure of 130 mm Hg D. Diastolic pressure of 110 mm Hg

Diastolic pressure of 110 mm Hg

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? A. "The client is unaware of his left side. You should approach him on the right side." B. "This condition is temporary." C. "The client is unaware of his left side. You need to encourage him to interact from this side." D. "The client is feeling an emotional loss. He'll eventually start acknowledging you on his left side."

"The client is unaware of his left side. You need to encourage him to interact from this side." *The client is experiencing unilateral neglect and is unaware of his left side.

The nurse is caring for a client diagnosed with a hemorrhagic stroke. The nurse recognizes that which intervention is most important? A. Elevating the head of the bed to 30 degrees B. Monitoring for seizure activity C. Maintaining a patent airway D. Administering a stool softener

C. Maintaining a patent airway *Maintaining the airway is the most important nursing intervention. Immediate complications of a hemorrhagic stroke include cerebral hypoxia, decreased cerebral blood flow, and extension of the area of injury.

When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke? A. The day before the patient is discharged B. After the nurse has received the discharge orders C. The day the patient has the stroke D. After the patient has passed the acute phase of the stroke

The day the patient has the stroke

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. Foot drop and external hip rotation B. Weakness on one side of the body and difficulty with speech C. Severe headache and early change in level of consciousness D. Vomiting and seizures

Weakness on one side of the body and difficulty with speech

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. slurred speech B. severe exploding headache C. difficulty finding appropriate words D. left-sided weakness

severe exploding headache