Chapter 28 & 29 - CVA and SCI

26. Which transitory symptoms might occur when a patient is diagnosed with a TIA? (Select all that apply.) "2DPT"

"2DPT" Dysphagia, Dysarthria (difficulty articulating speech) Ptosis (drooping or falling of upper eyelid) Tinnitus (ringing) All, except transitory incontinence, are classic symptoms of a TIA. These deficits usually disappear without permanent disability in approximately 24 hours.

32. What causes the 3% of strokes known to occur in persons younger than 45 years of age? (Select all that apply.) "BRADS LEUKEMIA"

"BRADS LEUKEMIA" BC Pills Rheumatic Fever A.Fib Drug Abuse Sickle Cell Anemia LEUKEMIA Strokes in younger people are caused by drug abuse, birth control pills, sickle cell anemia, leukemia, atrial fibrillation, and rheumatic fever. Alcohol abuse and hemophilia do not have a causative role in stroke.

25. The family of a patient with an SCI is concerned with the lack of bowel function 2 days after the injury. What is the best response by the nurse?

"Bowel function should return in approximately 3 days after the accident." Bowel action usually returns with peristalsis on the third day after the accident. The bowel responds to dilation from the content in the bowel and moves without voluntary action from the patient.

22. Which statement made by a male patient with an SCI could be assessed as a positive adaptation to the nursing diagnosis of "Sexual dysfunction, related to altered body function"?

"Can you arrange an appointment with a sex counselor so I can begin to examine alternative methods of sexual activity?" Seeking help from a counselor indicates an acceptance of learning alternative techniques. Remarks eliminating all possibilities of a sexual relationship are defeatist remarks and are not positive. However, a patient should realize that his or her sexual relationships will alter as a result of the SCI.

4. A nurse is updating a teaching plan for a patient who sustained a TIA. What should the nurse be sure to include?

Daily aspirin dose Daily aspirin reduces platelet aggregation and may prevent another attack. Reductions of fluid and long rest periods encourage clot formation.

16. A patient with an SCI begins to have seizures, and the blood pressure (BP) rises rapidly to 210/160 mm Hg. Which is the third indicator of the syndrome of autonomic dysreflexia?

Bradycardia Bradycardia, hypertension, and seizure are the three signs of autonomic dysreflexia.

31. A nurse is caring for a despondent young female patient with an SCI at C5. The patient verbalizes concern regarding sexual dysfunction. What should the nurse assure this patient she can still experience? (Select all that apply.) "INC"

"INC" Intercourse Normal menses Children Intercourse, normal menses, and childbirth are all possible for a woman with a C5 lesion, but no vaginal sensation occurs. Orgasm is possible but NOT vaginally stimulated.

2. On admission to the emergency department, a patient with a C5 compression fracture can move only his head and has flaccid paralysis of all extremities. The distraught family asks if the paralysis is permanent. What is the best response by the nurse?

"It is too early to tell. When the spinal shock subsides, we will know more." Spinal shock caused by swelling may last from a few days to months, clouding the issue of the true extent of the injury.

22. A patient in the rehabilitation phase after a CVA accidentally knocks the adapted plate from the table and bursts into tears after failing to feed himself. What is the best response by the nurse?

"Learning new skills is hard. Let's see what may have caused the trouble." Recognizing effort and showing support are the best approaches to depression and frustration. Babying the patient and admonitions against crying add to the problem. Redirection to the task at hand is therapeutic.

33. A nurse checks the oxygen in the circulating volume for adequate concentration to support the brain's need of _____% of the oxygen supply of the body.

20% The brain requires 20% of the available oxygen to function and to avoid hypoxic damage.

10. Several days after a CVA, a patient's family asks a nurse if tissue plasminogen activator (tPA) is a drug therapy option now. The nurse's response is based on the knowledge that this drug must be used within how many hours after the onset of symptoms?

3 tPA is to be given within 3 hours of the onset of symptoms per the U.S. Food and Drug Administration's guidelines. In some special treatment centers this drug is given intravenously up to 6 hours after the stroke.

17. A patient in the acute phase of an embolic CVA has an order for 400 units of heparin per hour IV. The heparin is in a solution of 5000 units/100 mL normal saline (NS). The nurse should set the electronic IV monitor at how many milliliters per hour?

8 Regardless of the method of calculation, 50 units of heparin are in each milliliter of the solution; 8 mL/hr delivers 400 units (5000 units ÷ 100 mL NS = 50 units/mL. 400 units ÷ 50 units/mL = 8 mL).

30. Which patients with CVAs are considered candidates for treatment with tPA? (Select all that apply.)

A 62-year-old construction worker who had a subdural hematoma 6 months earlier A 19-year-old young adult with leukemia with a platelet count of 200,000 The criteria for exclusion are a head injury within the last 3 months, a platelet count less than 100,000, active gastrointestinal bleeding, current treatment with an anticoagulant, and a seizure noted at the time of the CVA.

2. Which patient is at the greatest risk for a CVA?

A 65-year-old African American man with hypertension Older African Americans have a higher incidence of CVA than occasional smokers, young persons, or athletes. Hypertension increases the risk.

26. What should a nurse explain when a patient with an SCI inquires what the physician means by a cone-down?

A detailed radiographic image will be taken of the spinal injury. A cone-down radiographic image provides a very detailed picture of the lesion.

15. Which assessment indicates a fluid volume excess in a patient in the acute phase of a CVA?

Adventitious breath sounds Crackles in the lung fields are a major indicator of fluid excess. The pulse and BP are elevated in fluid excess. Urine-specific gravity is low in fluid excess.

19. A patient with homonymous hemianopsia is in the rehabilitation phase of a CVA. When arranging this patient's environment where should the nurse assure persons approaching and important items are visible and available?

Affected side Making the patient scan the affected side helps stimulate the return of normal function in the rehabilitation phase.

29. How does a lacunar stroke differ from an ischemic CVA? (Select all that apply.)

Affects small arteries Produces a small amount of neurologic damage The lacunar CVA only affects small arteries and produces a small amount of neurologic damage.

7. What should a nurse ensure as a priority for a patient immediately after a CVA?

Airway maintenance Adequate oxygenation prevents hypoxemia, which can extend and worsen effects of the CVA.

13. A distressed family member asks about the purpose of the Gardner-Wells tongs. Which is the most helpful explanation by the nurse regarding the action of Gardner-Wells tongs?

Align the cervical vertebrae. The Gardner-Wells tongs are secured to the skull to separate and align the cervical vertebrae, but they do not immobilize the head. When the tongs are in place, the patient is bedridden.

14. What is the major advantage of the halo device over the Gardner-Wells tongs?

Allows the patient out of bed The halo device and the Gardner-Wells tongs do exactly the same thing in terms of separation and alignment. The only advantage of the halo device is the mobility it allows. Neither traction modality specifically relieves pain.

32. A home health nurse encourages the family of a patient with an SCI to use the assisted cough technique. What does this technique require the caregiver to do?

Apply pressure to diaphragm as the patient coughs. To assist the patient with an SCI to cough, the caregiver applies pressure on the diaphragm as the patient attempts to cough after having taken a deep breath.

24. What should a nurse include in a patient's plan of care when considering interventions for the outcome of prevention of contractures in a patient with an SCI?

Apply splints to the limbs. Applying splints will reduce contractures. Cold application, agitation of the limb with ROM exercises too frequently, and tactile stimuli increase spasticity.

29. What changes occur with the intervertebral disks in older adults that increase the risk of injury? (Select all that apply.)

Are less shock absorbent Lose water Age affects the water content in intervertebral disks, which makes them less able to absorb shock. Herniation and swelling can occur at any age. Disks do not fill with calcium.

3. A patient experienced a period of momentary confusion, dizziness, and slurred speech but recovered in 2 hours. Which assessment in the diagnosis of this episode would be most helpful?

Auscultation of a bruit over the carotid artery A carotid bruit is evidence of a narrowing in that vessel, a symptom of a possible CVA or transient ischemic attack (TIA). BP of 140/90 mm Hg, although at the high end, is considered within normal limits. Headache and nausea alone are too common to be definitive.

8. Which technique of opening the airway in the newly admitted patient with an SCI is the most appropriate?

Jaw thrust The jaw thrust does not require spinal movement.

21. A nurse notes that no urinary output has occurred in a patient who underwent a laminectomy 2 hours earlier. What action should the nurse implement?

Continue to monitor. The nurse should continue to monitor the patient for urine output. Two hours is too soon to expect a continent patient to void. Informing the charge nurse and catheterization are not necessary. Turning this patient to the side is contraindicated.

27. What should a nurse encourage a patient with an SCI to do after a computed tomography (CT) scan?

Drink plenty of water. Fluids are pushed after a CT scan to flush the contrast media through the kidneys.

30. Before taking a magnetic resonance image (MRI), a patient asks why metal objects and the MRI machine are such concerns. What is the best explanation by the nurse regarding the MRI machine? (Select all that apply.)

Deactivates the battery in a pacemaker Attracts any metal into the MRI chamber The magnetic field will deactivate the batteries in a pacemaker and will also attract any metal object into the MRI chamber.

28. What signs and symptoms characterize expressive aphasia?

Difficulty initiating speech Expressive aphasia makes it difficult for the patient to initiate speech.

14. Pneumonia is the most frequent cause of death after a stroke. Which intervention would be contraindicated in the acute care of a patient with a hemorrhagic CVA?

Encourage forceful coughing to stimulate deep breathing. Forceful coughing is contraindicated for the patient with a hemorrhagic CVA because it may cause increased intracranial pressure.

18. Which intervention by a nurse is effective in the prevention of autonomic dysreflexia in the patient with an SCI?

Ensure patency of the urinary catheter. A distended bladder, constipation, and sudden jarring can all set off autonomic dysreflexia. Vagal stimulation retards vasodilation. The number and size of meals have no affect on preventing this syndrome.

21. Which is the most effective intervention for best support of regular bowel elimination and the prevention of constipation?

Give stool softeners daily, establishing a consistent time to attempt elimination. Daily stool softeners, rather than daily laxatives or frequent enemas, help restore regularity and bowel tone.

12. A patient who has sustained a hemorrhagic stroke is placed on a protocol of 60 mg of calcium channel blocker (nimodipine) every 4 hours. The patient's pulse is 82 beats/min before the administration of the prescribed dose. Which action should the nurse implement?

Give the full dose as prescribed without further assessment. The dose should be given; it would be held only if the pulse is below 60 beats/min. Assessments should be made regarding BP, urine output, and edema.

6. A patient has had a complete stroke as a result of a ruptured vessel in the left hemisphere. How should this patient's CVA be classified?

Hemorrhagic, intracerebral A ruptured vessel in a hemisphere is an intracerebral hemorrhagic CVA. It did not occur in the subarachnoid space. Ischemic CVAs are the result of occluded vessels.

27. What purposes exist for a stent in the carotid artery of a person with a TIA?

Keep the artery open. The only purpose of a stent is to keep an artery open.

9. Brown-Séquard syndrome results in which neurologic deficit?

Ipsilateral loss of motor function and contralateral loss of pain sensation and temperature Brown-Séquard syndrome is a hemisection of the cord resulting in ipsilateral motor loss and contralateral loss of pain and temperature.

11. A nurse explains that a lumbar puncture is most helpful as a diagnostic tool for a new patient who has had a CVA. What would this diagnostic test help determine regarding the stroke?

It is hemorrhagic or embolic. Blood in the spinal fluid indicates a hemorrhagic stroke and will help direct medical protocol in the subsequent treatment.

13. During the acute CVA phase, a risk for falls related to paralysis is present. Which intervention best protects the patient from injury?

Keep the side rails up, according to agency policy. Rails keep patients in bed. The bed should be low, monitoring the patient should be more frequent than every 2 hours, and visual assessment is not directly related to fall prevention.

5. During a neurologic assessment, a nurse asks a patient to dorsiflex the foot against the resistance of the nurse's hand. The patient is unable to perform this action. Where does this assessment confirm that cord damage has occurred?

L5 The muscle group that controls the feet is at L5.

1. A patient has weakness on the right side and impaired reasoning after having a cerebrovascular accident (CVA). What part of the brain is affected?

Left hemisphere of the cerebrum Impaired motor strength on the right side in conjunction with impaired reasoning indicates a lesion in the left hemisphere of the cerebrum. The cerebellum controls balance and is not contralateral.

20. Which outcome criterion is the most appropriate for a patient with "Imbalanced nutrition, related to dysphagia, with the goal of adequate nutrition"?

Maintains body weight of 150 to 155 lb The maintenance of a desired weight is indicative of adequate nutrition. Eating a portion of a meal or eating independently does not adequately measure the extent to which the goal was met. Offering a variety of foods is a nursing or dietary function, not an outcome.

23. Which instruction is most helpful in teaching the family and patient who is in the rehabilitation phase after a CVA about altered sensation?

Make frequent assessments for signs of pressure or injury. Frequent assessment using the National Institutes of Health Stroke Scale will allow early detection. The use of hot or cold applications and using the affected limbs in transfer or ambulation may cause injury.

10. Which level of independence is an appropriate nursing care plan goal for a patient with a C8 transection?

Manage an ordinary wheelchair. Upper extremity mobility and enhanced hand grip allow the use of an ordinary wheelchair by an individual with a C8 level SCI.

6. What technique should the nurse implement to move the impaired legs of a patient with an SCI to avoid stimulation muscle spasm?

Manipulating the limb by supporting the knee and ankle joints Undue muscle stimulation can cause spasticity. Using the joint locations to support limbs when repositioning them reduces likelihood of spasticity.

7. When recording the findings of muscle strength, a nurse records a 2 for the right arm. How should his score be interpreted?

Muscle movement when supported A 2 on the muscle-grading scale means that muscular movement is observed when the limb is supported.

18. Which assessment indicates that a patient with a CVA is in transition to the rehabilitation phase? a. BP has been within normal limits for 24 hours. b. Patient makes positive statements about his condition.

No further neurologic deficits are observed. When no further deficits are noted and all vital signs have stabilized, the patient is considered to be in the rehabilitation phase. Positive statements and attempts at independence are not sufficient.

19. A nurse tells a patient with quadriplegia that he is being treated with intravenous (IV) drugs because this method is more effective than intramuscularly (IM). What explanation should the nurse provide about IM medications to explain to the patient why they are less effective than IV?

Not absorbed well below the level of the injury A patient with quadriplegia has a high cervical lesion, which causes nearly the entire vascular tree to have poor perfusion. This condition would make absorption of medications from the tissues unpredictable.

5. A patient recovering from a CVA asks the purpose of the warfarin (Coumadin). What is the best response by the nurse regarding the purpose of Coumadin?

Prevents the formation of new clots. Coumadin and heparin prevent more clots rather than dissolving them. Coumadin has no effect on vasodilation or blood cell production.

17. What should be the immediate intervention when a nurse recognizes autonomic dysreflexia in the patient with an SCI?

Raise the head of the bed to at least 45 degrees. Raising the head of the bed reduces the BP. Flexed legs, cooling, and oxygen will not alleviate the syndrome.

31. Which home modifications will support rehabilitation for a patient who had a stroke? (Select all that apply.)

Raised commode seat Provision of a seat in the shower Bathtub hand rails A raised commode seat, a seat in the shower, and bathtub rails assist the patient who is recovering from a stroke with self-care. Low chairs are difficult to manage, and scatter rugs pose a hazard for falls.

15. A patient is receiving methylprednisolone. What purpose should the nurse explain this drug has in treating a patient with an SCI?

Reduces spinal cord cellular damage Methylprednisolone, if given within the first 8 hours of the injury, can significantly reduce cellular damage to the cord.

11. A paraplegic patient excitedly reports seeing his foot move when he was being turned. How is this phenomenon best explained?

Reflexive movement Reflexive action is a movement that does not require communication to the brain via the spinal cord.

23. What should a nurse emphasize regarding the rehabilitation of the patient with an SCI?

Rehabilitation focuses on adjustments necessary to reenter society and the workplace. The goals of rehabilitation are modification of lifestyle, as well as expectations and adjustments, necessary to attain the highest level of independence possible.

1. A nurse explains that the spinal cord extends from the brainstem to the level of which vertebra?

Second lumbar The cord starts at the brainstem and extends to the second lumbar vertebra.

3. Which assessment would indicate the resolution of spinal shock?

Spastic involuntary movements in affected limbs Spastic involuntary movements after a period of flaccid paralysis announce the end of spinal shock.

12. After spinal shock has been resolved, an indwelling catheter is removed. What way should the nurse expect this patient to empty the bladder?

Spontaneous reflexive action After spinal shock resolves, spasticity of the bladder causes spontaneous emptying.

25. The wife of a husband who has had a CVA asks why he is being treated with insulin since he has no history of diabetes. What is the best response by the nurse as to why hyperglycemia occurs after a stroke?

Stress Hyperglycemia occurs after a CVA as the body's response to stress. If left untreated, the hyperglycemia will cause increased brain damage and worsen the outcome of the stroke.

9. A patient in the acute phase of a CVA who has been speaking distinctly begins to speak indistinctly and only with great effort but still coherent. What should this nurse determine when assessing this patient?

Stroke in evolution with dysarthria As symptoms worsen, the CVA is still evolving. Speech that is coherent but difficult is dysarthria rather than any type of aphasia. Dyspraxia is a motor impairment, not a speech impairment.

16. Which intervention should the nurse include in a patient's plan of care to help preserve joint mobility in the acute phase of a CVA?

Support affected points in good functional alignment. Limbs maintained in a functional anatomic position and gently exercised (never pulled) into an acceptable range of motion several times during a shift will maintain optimal mobility.

20. The family members of a patient with an SCI, who is in the rehabilitation phase, wants to take the patient outdoors for a visit. It is 90° F outside and very humid. What should the nurse suggest?

Take a spray bottle to spray water to cool the patient by evaporation. Water will evaporate and cool the patient, similar to perspiration.

28. What has occurred in the past 10 years to enhance rehabilitation of individuals with SCIs? (Select all that apply.)

Technologically advanced assistive aids Development of trauma centers Rapid transport of victims New assistive aids, the development of decentralized trauma centers, and the rapid transport of victims have all increased the potential for rehabilitation. Rehabilitation personnel and health insurance are not new.

24. Which posthospital option should the nurse encourage a patient to do when recovering from a CVA to provide the most comprehensive assistance?

Transfer to a rehabilitation center. A rehabilitation center with all modalities of support (e.g., physical therapy, occupational therapy, speech therapy, simulated home environments) is obviously the best option.

4. Which assessment leads the emergency department nurse to suspect that a patient's spinal cord injury (SCI) is below C4?

Unlabored respiration The phrenic nerve, which is at C1 to C4, controls the diaphragm and intercostal function for ventilation.

8. When should a nurse recognize that the acute phase of a CVA has ended?

Vital signs and neurologic signs stabilize. When the vital and neurologic signs stabilize, the acute phase has ended. Verbal response, lower BP, and the passage of time without other signs are not adequate evidence that the acute phase has ended.

33. A nurse refers to the _____ to assess the extent of sensory loss and specific nerve root enervation.

dermatome chart The assessment of the level and extent of sensory loss and, consequently, the affected nerve roots involved can be performed with the assistance of a dermatome chart.