Chapter 38: Caring for Clients with Cerebrovascular Disorders

A rehabilitation nurse caring for a client who has had a stroke is approached by the client's family and asked why the client has to do so much for self-care while obviously struggling to do so. What would be the nurse's best answer? "Rehabilitation means helping clients do exactly what they did before their stroke." "We aren't here to care for the client the way the hospital staff did; we are here to help the client get better and return home." "We are trying to help the client be as useful as possible." "The focus on care in a rehabilitation facility is to help the client to resume as much self-care as possible."

"The focus on care in a rehabilitation facility is to help the client to resume as much self-care as possible." Explanation: In both acute care and rehabilitation facilities, the focus is on teaching the client to resume as much self-care as possible. The goal of rehabilitation is not to be "useful," nor is it to return clients to their pre-stroke level of functioning, which may be unrealistic.

During a client's recovery from stroke, the nurse should be aware of predictors of stroke outcome in order to help clients and families set realistic goals. What are the predictors of stroke outcome? Select all that apply. -LOC at time of admission -National Institutes of Health Stroke Scale (NIHSS) score -Race -Age -Gender

-National Institutes of Health Stroke Scale (NIHSS) score -LOC at time of admission -Age Explanation: It is helpful for clinicians to be knowledgeable about the relative importance of predictors of stroke outcome (age, NIHSS score, and LOC at time of admission) to provide stroke survivors and their families with realistic goals. Race and gender are not significant predictors of stroke outcome.

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. -Follow the healthcare provider's orders to increase fluid volume. -Maintain the head of the bed at 30 degrees. -Use a well-lighted room for assessments every 2 hours. -Avoid any activities that cause a Valsalva maneuver.

-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. Explanation: Cerebral aneurysm precautions are implemented for the patient with a diagnosis of aneurysm to provide a nonstimulating environment, prevent increases in intracranial pressure, and prevent further bleeding. The patient is placed on bed rest in a quiet, nonstressful environment, because activity, pain, and anxiety are thought to elevate the blood pressure, which may increase the risk for bleeding. The head of the bed is elevated 30 degrees to promote venous drainage and decrease intracranial pressure. Any activity that suddenly increases the blood pressure or obstructs venous return is avoided. This includes the Valsalva maneuver, straining, forceful sneezing, pushing oneself up in bed and acute flexion or rotation of the head and neck (which compromises the jugular veins). Stool softeners and mild laxatives are prescribed to prevent constipation, which can cause an increase in intracranial pressure. Dim lighting is helpful for photophobia. Increasing fluid volume does not affect brain bleeding.

An emergency department nurse understands that a 110-lb (50-kg) recent stroke victim will receive at least the minimum dose of recombinant tissue plasminogen activator (t-PA). What minimum dose will the client receive? -45 mg -90 mg -50 mg -85 mg

45 mg Explanation: The client is weighed to determine the dose of t-PA. Typically, two or more IV sites are established prior to administration of t-PA (one for the t-PA and the other for administration of IV fluids). The dosage for t-PA is 0.9 mg/kg, with a maximum dose of 90 mg. 50 kg X 0.9 mg= 45 mg dose

A client with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this client? -Passive range-of-motion exercises to prevent contractures -Early initiation of physical therapy -Absolute bed rest in a quiet, non stimulating environment -Supine positioning

Absolute bed rest in a quiet, non stimulating environment Explanation: The client is placed on immediate and absolute bed rest in a quiet, nonstressful environment because activity, pain, and anxiety elevate BP, which increases the risk for bleeding. Visitors are restricted. The nurse administers all personal care. The client is fed and bathed to prevent any exertion that might raise BP. Clients with increased ICP are normally positioned with the HOB elevated.

A nurse who provides care at a community clinic is in contact with a diverse group of patients. Which of the following individuals most clearly displays risk factors for stroke? A man who is receiving oral antibiotics for the treatment of a chlamydial infection A 70-year-old man who has benign prostatic hyperplasia and early stage Alzheimer's disease A woman who has osteoporosis, a history of fractures, and a family history of stroke An obese woman with a history of atrial fibrillation and type 2 diabetes

An obese woman with a history of atrial fibrillation and type 2 diabetes Explanation: Obesity, atrial fibrillation, and type 2 diabetes are all highly significant risk factors for stroke. None of the other listed individuals displays multiple risk factors for stroke.

Which of the following, if left untreated, can lead to an ischemic stroke? -Atrial fibrillation -Arteriovenous malformation (AVM) -Cerebral aneurysm -Ruptured cerebral arteries

Atrial fibrillation Explanation: Atrial fibrillation is the most frequently diagnosed arrhythmia in the United States. If left untreated, it can lead to an ischemic stroke. Cerebral hemorrhage, arteriovenous malformation, and cerebral hemorrhage can lead to a hemorrhagic stroke. Cerebral aneurysm, arteriovenous malformations, and ruptured cerebral arteries can lead to hemorrhagic stroke.

A preceptor discussing stroke with a new nurse on the unit would tell the new nurse that which cardiac dysrhythmia is associated with cardiogenic embolic strokes? -Ventricular tachycardia -Bundle branch block -Atrial fibrillation -Supraventricular tachycardia

Atrial fibrillation Explanation: Cardiogenic embolic strokes are associated with cardiac dysrhythmias, usually atrial fibrillation. The other listed dysrhythmias are less commonly associated with this type of stroke.

A client recently had a stroke. Now the client has spasms in his/her hands, which is preventing a favorite hobby of knitting. The client is looking for a permanent solution to this problem. Which therapies would the nurse recommend? -Botulinum toxin type A and heat -Baclofen and stretching -Amitriptyline and splinting -Corticosteroids and acupuncture

Baclofen and stretching Explanation: Treatments for spasticity may include stretching, splinting (in select clients), and oral medications such as baclofen and tizanidine. Studies concerning splitting debate the effectiveness of this treatment. Botulinum toxin type A injected intramuscularly into wrist and finger muscles has been shown to be effective in reducing this spasticity but the effect is temporary, typically lasting 2 to 4 months. Amitriptyline is more effective for post-stroke pain and depression. Corticosteroids, heat therapy, and acupuncture are recommended for shoulder pain after a client has a stroke.

The nurse is discharging to home a client who experienced a stroke resulting in a flaccid right arm and leg and problems with urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common client response to a change in body image? -Depression -Denial -Fear -Disassociation

Depression Explanation: Depression is a common and serious problem in the client who has had a stroke. It can result from a profound disruption in their life and changes in total function, leaving the client with a loss of independence. The nurse needs to encourage the client to verbalize feelings to assess the effect of the stroke on self-esteem. Denial, fear, and disassociation are not the most common client response to a change in body image, although each can occur in some clients.

A nursing student is writing a care plan for a newly admitted client who has been diagnosed with a stroke. What major nursing diagnosis should most likely be included in the client's plan of care? -Hyperthermia -Disturbed sensory perception -Post-trauma syndrome -Adult failure to thrive

Disturbed sensory perception Explanation: The client who has experienced a stroke is at a high risk for disturbed sensory perception. Stroke is associated with multiple other nursing diagnoses, but hyperthermia, adult failure to thrive, and post-trauma syndrome are not among these.

A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to perform which action? -Speak at all -Comprehend spoken words -Form words that are understandable or comprehend spoken words -Form words that are understandable

Form words that are understandable or comprehend spoken words Explanation: Global aphasia is a combination of expressive and receptive aphasia and presents a tremendous challenge to the nurse to effectively communicate with the client. In receptive and expressive aphasia, the client is unable to form words that are understandable. The client who is unable to speak at all is referred to as mute.

When preparing to discharge a client home, the nurse has met with the family and warned them that the client may exhibit unexpected emotional responses. The nurse should teach the family that these responses are typically a result of what cause? -Temporary changes in metabolism -Unmet physiologic needs -Frustration around changes in function and communication -Changes in brain activity during sleep and wakefulness

Frustration around changes in function and communication Explanation: Emotional problems associated with stroke are often related to the new challenges around ADLs and communication. These challenges are more likely than metabolic changes, unmet physiologic needs, or changes in brain activity, each of which should be ruled out.

Which is the most common motor dysfunction seen in clients diagnosed with stroke? -Hemiplegia -Ataxia -Hemiparesis -Diplopia

Hemiplegia Explanation: The most common motor dysfunction is hemiplegia (paralysis of one side of the body) caused by a lesion on the opposite side of the brain. Ataxia is impaired ability to coordinate movement. Diplopia is double vision. Hemiparesis is weakness of one side of the body.

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 -Peripheral edema -Fluid overload -Acute pain

Hemorrhage Explanation: Bleeding is the most common side effect of tPA. The patient is closely monitored for bleeding (at IV insertion sites, gums, urine/stools, and intracranially by assessing changes in level of consciousness). Edema, fluid overload, and pain are not likely to result from tPA.

A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? -Heparin sodium -Phenytoin -Methyldopa -Dexamethasone

Heparin sodium Explanation: Administering heparin, an anticoagulant, could increase the bleeding associated with hemorrhagic stroke. Therefore, the nurse should question this order to prevent additional hemorrhage in the brain. In a client with hemorrhagic stroke, the healthcare provider may use dexamethasone (Decadron) to decrease cerebral edema and pressure, methyldopa (Aldomet) to reduce blood pressure, and phenytoin (Dilantin) to prevent seizures.

A client diagnosed with a hemorrhagic stroke has been admitted to the neurologic ICU. The nurse knows that teaching for the client and family needs to begin as soon as the client is settled on the unit and will continue until the client is discharged. What will family education need to include? How to differentiate between hemorrhagic and ischemic stroke Techniques for adjusting the client's medication dosages at home How to correctly modify the home environment Risk factors for ischemic stroke

How to correctly modify the home environment Explanation: For a client with a hemorrhagic stroke, teaching addresses the use of assistive devices or modification of the home environment to help the client live with the disability. This is more important to the client's needs than knowing about risk factors for ischemic stroke. It is not necessary for the family to differentiate between different types of strokes. Medication regimens should never be altered without consultation.

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: -Obesity -Dyslipidemia -Smoking -Hypertension

Hypertension Explanation: Hypertension is the most modifiable risk factor for either ischemic or hemorrhagic stroke. Unfortunately, it remains under-recognized and undertreated in most communities.

The nurse is educating a group of nursing students about COVID-19 and risk for cerebrovascular disorders. The nurse educator notes that COVID-19 has shown to increase which condition? - Ischemic stroke -Decrease inflammation -Hemorrhagic stroke -Hypertension

Ischemic stroke Explanation: Blood clotting abnormalities have been found to occur in COVID-19 afflicted clients. With the clotting abnormalities, there is an increased risk for ischemic stroke. There is no evidence that COVID-19 causes any of the other conditions.

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention? -Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess -Positioning the client to prevent airway obstruction -Keeping the client in one position to decrease bleeding -Maintaining the client in a quiet environment

Keeping the client in one position to decrease bleeding Explanation: The student nurse shouldn't keep the client in one position. She should carefully reposition the client often (at least every hour). The client needs to be positioned so that a patent airway can be maintained. Fluid administration must be closely monitored to prevent complications such as increased intracranial pressure. The client must be maintained in a quiet environment to decrease the risk of rebleeding.

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

Left visual field deficit Explanation: A left visual field deficit is a common clinical manifestation of a right hemispheric stroke. Aphasia, slow, cautious behavior, and altered intellectual ability are all clinical manifestations of a left hemispheric stroke.

A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem? -Diphenhydramine (Benadryl) -Heparin -Lioresal (Baclofen) -Pregabalin (Lyrica)

Lioresal (Baclofen) Explanation: Spasticity, particularly in the hand, can be a disabling complication after stroke. Botulinum toxin type A injected intramuscularly into wrist and finger muscles has been shown to be effective in reducing this spasticity (although the effect is temporary, typically lasting 2 to 4 months) (Teasell, Foley, Pereira, et al., 2012). Other treatments for spasticity may include stretching, splinting, and oral medications such as baclofen (Lioresal).

A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem? -Diphenhydramine (Benadryl) -Lioresal (Baclofen) -Heparin -Pregabalin (Lyrica)

Lioresal (Baclofen) Explanation: Spasticity, particularly in the hand, can be a disabling complication after stroke. Botulinum toxin type A injected intramuscularly into wrist and finger muscles has been shown to be effective in reducing this spasticity (although the effect is temporary, typically lasting 2 to 4 months) (Teasell, Foley, Pereira, et al., 2012). Other treatments for spasticity may include stretching, splinting, and oral medications such as baclofen (Lioresal).

A transcranial Doppler ultrasonography detects cerebral vasospasms in a client experiencing lethargy 8 days following a subarachnoid hemorrhage. The nurse anticipates which therapeutic intervention? -Nimodipine PO -Nitroprusside IV -Phenytoin IV -Fluid restriction

Nimodipine PO Explanation: Medication may be effective in the treatment of vasospasm. Based on one theory, that vasospasm is caused by an increased influx of calcium into the cell, medication therapy may be used to block or antagonize this action and prevent or reverse the action of vasospasm if already present. The most frequently used calcium channel blocker is nimodipine. The other interventions and medications are not used to treat vasospasms.

A client is diagnosed with a right-sided stroke. The client is now experiencing hemianopsia. How might the nurse help the client manage the potential sensory and perceptional difficulties? -Keep the lighting in the client's room low. -Approach the client on the side where vision is impaired. -Place the client's extremities where the client can see them. -Place the client's clock on the affected side.

Place the client's extremities where the client can see them. Explanation: The client with homonymous hemianopsia (loss of half of the visual field) turns away from the affected side of the body and tends to neglect that side and the space on that side; this is called amorphosynthesis. In such instances, the client cannot see food on half of the tray, and only half of the room is visible. It is important for the nurse to remind the client constantly of the other side of the body, to maintain alignment of the extremities, and if possible, to place the extremities where the client can see them. Clients with a decreased field of vision should be approached on the side where visual perception is intact. All visual stimuli (clock, calendar, and television) should be placed on this side. The client can be taught to turn the head in the direction of the defective visual field to compensate for this loss. Increasing the natural or artificial lighting in the room and providing eyeglasses are important in increasing vision. There is no reason to keep the lights dim.

Nursing care during the immediate recovery period from an ischemic stroke should normally prioritize which intervention? -Positioning the client to avoid intercranial pressure (ICP) -Initiating early mobilization -Administering hypertonic intravenous (IV) solution -Maximizing partial pressure of carbon dioxide (PaCO2)

Positioning the client to avoid intercranial pressure (ICP) Explanation: Interventions during this period include measures to reduce ICP, such as administering an osmotic diuretic (e.g., mannitol) and positioning to avoid ICP, and handle secretions to avoid aspiration. Hypertonic IV solutions are not used unless sodium depletion is evident. PaCO2 must remain within an acceptable range, not maximized. Mobilization would take place after the immediate threat of increased ICP has passed.

A client has tension headaches. The nurse recommends massage as a treatment for tension headaches. How does massage help clients with tension headaches? -Reduces hypotension -Increases appetite -Relaxes muscles -Relieves migraines

Relaxes muscles Explanation: Massaging relaxes tense muscles, causes local dilation of blood vessels, and relieves headache. However, this approach is not likely to help a client with migraine or cluster headaches. Massage is not offered to clients with tension headaches to increase their appetite or reduce hypotension.

The nurse practitioner is able to correlate a patient's neurologic deficits with the location in the brain affected by ischemia or hemorrhage. For a patient with a left hemispheric stroke, the nurse would expect to see: -Impulsive behavior. -Right-sided paralysis. -Left visual field deficit. -Spatial-perceptual deficits.

Right-sided paralysis. Explanation: A left hemispheric stroke will cause right-sided weakness or paralysis. Because upper motor neurons decussate, a disturbance on one side of the body can cause damage on the opposite side of the brain. Refer to Box 47-2 in the text.

The nurse is educating a group of students about complications of an aneurysm. Which is a complication of aneurysm? -Airway collapse -Seizure -Hypernatremia -Pneumothorax

Seizure Explanation: Due to increased intracranial pressure, there is a risk for the client developing seizures. Hyponatremia, not hypernatremia, can occur. Airway collapse and pneumothorax do not occur as a complication of an aneurysm.

The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient? -High-Fowler's -Supine -Semi-Fowler's -Prone

Semi-Fowler's Explanation: The head of the bed is elevated 15 to 30 degrees (semi-Fowler's position) to promote venous drainage and decrease intracranial pressure.

Which is a modifiable risk factor for transient ischemic attacks and ischemic strokes? -Thyroid disease -Social drinking -Advanced age -Smoking

Smoking Explanation: Modifiable risk factors for TIAs and ischemic stroke include hypertension, diabetes, cardiac disease, smoking, and excessive alcohol consumption. Advanced age, gender, and race are nonmodifiable risk factors for stroke.

A client who has experienced an ischemic stroke has been admitted to the medical unit. The client's family is adamant that the client remain on bed rest to hasten recovery and to conserve energy. What principle of care should inform the nurse's response to the family? The client should mobilize as soon as physically able. To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks. Lack of mobility will greatly increase the client's risk of stroke recurrence. The client should remain on bed rest until the client expresses a desire to mobilize.

The client should mobilize as soon as physically able. Explanation: As soon as possible, the client is assisted out of bed and an active rehabilitation program is started. Delaying mobility causes complications, but not necessarily stroke recurrence. Mobility should not be withheld until the client initiates.

A nurse is teaching a community class that those experiencing symptoms of ischemic stroke need to enter the medical system early. The primary reason for this is which of the following? -Thrombolytic therapy has a time window of only 3 hours. -Intracranial pressure is increased by a space-occupying bleed. -A ruptured arteriovenous malformation will cause deficits until it is stopped. -A ruptured intracranial aneurysm must quickly be repaired.

Thrombolytic therapy has a time window of only 3 hours. Explanation: Currently approved thrombolytic therapy for ischemic strokes has a treatment window of only 3 hours after the onset of symptoms. Urgency is needed on the part of the public for rapid entry into the medical system. The other three choices are related to hemorrhagic strokes.

If warfarin is contraindicated as a treatment for stroke, which medication is the best option? -Dipyridamole -Clopidogrel -Ticlodipine -aspirin

aspirin Explanation: If warfarin is contraindicated, aspirin is the best option, although other medications may be used if both are contraindicated.

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? -diabetes insipidus -cardiac disease -hypertension -impaired cerebral circulation

impaired cerebral circulation Explanation: TIAs involve the same mechanism as in the ischemic cascade, but symptoms are transient (< 24 hours) and there is no evidence of cerebral tissue infarction. The ischemic cascade begins when cerebral blood flow decreases to less than 25 mL/100 g/min and neurons are no longer able to maintain aerobic respiration. Thus, a TIA results directly from impaired blood circulation in the brain. Atherosclerosis, cardiac disease, hypertension, or diabetes can be risk factors for a TIA but do not cause it.

A nurse is taking care of a client with swallowing difficulties after a stroke. What are some interventions the nurse can accomplish to prevent the client from aspirating while eating? Select all that apply. Assist the client out of bed and into the chair for meals. Instruct the client to tuck his/her chin towards their chest when swallowing. Encourage the client to increase his/her intake of water and juice. Request a swallowing assessment by a speech therapist before the client's discharge. Recommend the insertion of a percutaneous endoscopic gastrostomy (PEG) tube.

-Assist the client out of bed and into the chair for meals. -Instruct the client to tuck his/her chin towards their chest when swallowing. Explanation: If swallowing function is partially impaired, it may return over time, or the client may be educated in alternative swallowing techniques, advised to take smaller boluses of food, and educated about types of foods that are easier to swallow. The client may be started on a thick liquid or pureed diet, because these foods are easier to swallow than thin liquids. Having the client sit upright, preferably out of bed in a chair, and instructing them to tuck the chin toward the chest as they swallow will help prevent aspiration. Recommending the insertion of a percutaneous endoscopic gastrostomy (PEG) tube would not prevent the client from aspirating while eating. A PEG tube could be placed if the client was unable to tolerate or resume an oral intake. A swallowing assessment should be done before allowing any oral intake and preferably within 4 to 24 hours after a stroke. A nurse can also accomplish a swallowing study using a validated and reliable assessment tool.

The pathophysiology of an ischemic stroke involves the ischemic cascade, which includes the following steps: 1. Change in pH occurs 2. Blood flow decreases 3. A switch to anaerobic respiration occurs 4. Membrane pumps fail 5. Cells cease to function 6. Lactic acid is generated Which of the following options is the correct order in which the ischemic cascade steps occur? -6, 3, 5, 2, 4, 1 -2, 3, 6, 1, 4, 5 -3, 5, 2, 4, 1, 6 -1, 6, 2, 5, 3, 4

2, 3, 6, 1, 4, 5 Explanation: The ischemic cascade begins when cerebral blood flow decreases to less than 25 mL per 100 g of blood per minute. At this point, neurons are no longer able to maintain aerobic respiration. The mitochondria must then switch to anaerobic respiration, which generates large amounts of lactic acid, causing a change in the pH. This switch to the less efficient anaerobic respiration also renders the neuron incapable of producing sufficient quantities of adenosine triphosphate (ATP) to fuel the depolarization processes. The membrane pumps that maintain electrolyte balances begin to fail, and the cells cease to function.

A community health nurse is giving an educational presentation about stroke and heart disease at the local senior citizens' center. What nonmodifiable risk factor for stroke should the nurse cite?

Advanced age Explanation: Advanced age is a nonmodifiable risk factor for stroke. Physical inactivity, hypertension, and tobacco use are all modifiable risks.

The nurse is taking care of a client with a headache. The nurse can take which measure to assist the client in reducing the pain associated with the headache? -Administer prescribed medications when pain intensifies. -Encouraging the client to participate in stimulating activities. -Use pressure-relieving pads or a similar type of mattress. -Apply warm or cool cloths to the forehead or back of the neck.

Apply warm or cool cloths to the forehead or back of the neck. Explanation: A method to reduce pain is to apply warm (or cool) cloths to the forehead or back of the neck. Warmth promotes vasodilation; cool reduces blood flow. Prescribed medications should be administered as early as possible, not held until pain intensifies. The client should avoid overly stimulating activities and instead provide distraction through soft, soothing music, or guided imagery. Pressure-relieving pads or a mattress would not significantly reduce this type of pain.

A client recently had a stroke. Now the client has spasms in his/her hands, which is preventing a favorite hobby of knitting. The client is looking for a permanent solution to this problem. Which therapies would the nurse recommend? -Baclofen and stretching -Botulinum toxin type A and heat -Amitriptyline and splinting -Corticosteroids and acupuncture

Baclofen and stretching Explanation: Treatments for spasticity may include stretching, splinting (in select clients), and oral medications such as baclofen and tizanidine. Studies concerning splitting debate the effectiveness of this treatment. Botulinum toxin type A injected intramuscularly into wrist and finger muscles has been shown to be effective in reducing this spasticity but the effect is temporary, typically lasting 2 to 4 months. Amitriptyline is more effective for post-stroke pain and depression. Corticosteroids, heat therapy, and acupuncture are recommended for shoulder pain after a client has a stroke.

The nurse is discharging to home a client who experienced a stroke resulting in a flaccid right arm and leg and problems with urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common client response to a change in body image? -Fear -Disassociation -Denial -Depression

Depression Explanation: Depression is a common and serious problem in the client who has had a stroke. It can result from a profound disruption in their life and changes in total function, leaving the client with a loss of independence. The nurse needs to encourage the client to verbalize feelings to assess the effect of the stroke on self-esteem. Denial, fear, and disassociation are not the most common client response to a change in body image, although each can occur in some clients.

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 -Comprehend spoken words -Form words that are understandable -Speak at all

Form words that are understandable or comprehend spoken words Explanation: Global aphasia is a combination of expressive and receptive aphasia and presents a tremendous challenge to the nurse to effectively communicate with the client. In receptive and expressive aphasia, the client is unable to form words that are understandable. The client who is unable to speak at all is referred to as mute.

A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem? -Heparin -Diphenhydramine (Benadryl) -Lioresal (Baclofen) -Pregabalin (Lyrica)

Lioresal (Baclofen) Explanation: Spasticity, particularly in the hand, can be a disabling complication after stroke. Botulinum toxin type A injected intramuscularly into wrist and finger muscles has been shown to be effective in reducing this spasticity (although the effect is temporary, typically lasting 2 to 4 months) (Teasell, Foley, Pereira, et al., 2012). Other treatments for spasticity may include stretching, splinting, and oral medications such as baclofen (Lioresal).

A client has tension headaches. The nurse recommends massage as a treatment for tension headaches. How does massage help clients with tension headaches? -Reduces hypotension -Increases appetite -Relaxes muscles -Relieves migraines

Relaxes muscles Explanation: Massaging relaxes tense muscles, causes local dilation of blood vessels, and relieves headache. However, this approach is not likely to help a client with migraine or cluster headaches. Massage is not offered to clients with tension headaches to increase their appetite or reduce hypotension.

The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient? -Semi-Fowler's -High-Fowler's -Supine -Prone

Semi-Fowler's Explanation: The head of the bed is elevated 15 to 30 degrees (semi-Fowler's position) to promote venous drainage and decrease intracranial pressure.

A patient is exhibiting classic signs of a hemorrhagic stroke. What complaint from the patient would be an indicator of this type of stroke? -Dizziness and tinnitus -Numbness of an arm or leg -Double vision -Severe headache

Severe headache Explanation: The patient with a hemorrhagic stroke can present with a wide variety of neurologic deficits, similar to the patient with ischemic stroke. The conscious patient most commonly reports a severe headache

The nurse is caring for a client recovering from a carotid endarterectomy. Which finding indicates to the nurse that the client is experiencing hyperperfusion syndrome? Decreased blood pressure Change in vision in one eye Difficulty breathing Severe unilateral headache

Severe unilateral headache Explanation: Hyperperfusion syndrome occurs when cerebral vessel autoregulation fails. Arteries accustomed to diminished blood flow may be permanently dilated. Increased blood flow after endarterectomy coupled with insufficient vasoconstriction leads to capillary bed damage, edema, and hemorrhage. A unilateral headache that improves by sitting upright or standing is an intervention for this syndrome. Difficulty breathing is an indication of an incisional hematoma. A drop in blood pressure is an indication of postoperative hypotension. A change in vision in one eye could indicate the development of a stroke.

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? -Three hours -One hour -Two hours -Six hours

Three hours Explanation: 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.

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? -hypertension -diabetes insipidus -cardiac disease -impaired cerebral circulation

impaired cerebral circulation Explanation: TIAs involve the same mechanism as in the ischemic cascade, but symptoms are transient (< 24 hours) and there is no evidence of cerebral tissue infarction. The ischemic cascade begins when cerebral blood flow decreases to less than 25 mL/100 g/min and neurons are no longer able to maintain aerobic respiration. Thus, a TIA results directly from impaired blood circulation in the brain. Atherosclerosis, cardiac disease, hypertension, or diabetes can be risk factors for a TIA but do not cause it.

A client reports frequent headaches and is seeing the physician to determine their cause. In client education, which type of headache does the nurse indicate is most common? -tension -cluster -secondary -migraine

tension Explanation: Tension headaches, the most common of the three, occur when a person contracts the neck and facial muscles for a prolonged period of time.

The nurse is providing diet-related advice to a client who experienced a cerebrovascular accident (CVA). The client wants to minimize his volume of food and yet meet all nutritional requirements. To control the volume of food intake, the nurse should suggest that the client consume:

thickened commercial beverages and fortified cooked cereals. Explanation: Clients with CVA or other cerebrovascular disorders should lose weight and, therefore, should minimize their volume of food consumption. To ensure this, the nurse may suggest thickened commercial beverages, fortified cooked cereals, or scrambled eggs.

A client has a 12-year history of cluster headaches. After the client describes the characteristics of the head pain, the nurse begins to discuss its potential causes. What would the nurse indicate that the origin of the headaches is: unknown. endocrine. muscular. vasodilating agents.

unknown. Explanation: Although cluster headaches can be triggered by vasodilating agents, the cause of cluster headaches is unknown.

A client has a 12-year history of cluster headaches. After the client describes the characteristics of the head pain, the nurse begins to discuss its potential causes. What would the nurse indicate that the origin of the headaches is: -unknown. -endocrine. -muscular. -vasodilating agents.

unknown. Explanation: Although cluster headaches can be triggered by vasodilating agents, the cause of cluster headaches is unknown.

The nurse is educating a group of people newly diagnosed with migraine headaches. What information should the nurse include in the educational session? Select all that apply. -Use St. John's Wort. -Exercise in a dark room. -Keep a food diary. -Maintain a headache diary. -Sleep no more than 5 hours at a time.

-Keep a food diary. -Maintain a headache diary. Explanation: The clients should be encouraged to keep food and headache diaries to identify triggers and to track frequency and characteristics of the migraines. The clients should maintain a routine sleep pattern and avoid fatigue. Limiting sleep to 5 hours may cause fatigue. The associated symptoms of a migraine are nausea, vomiting, and photophobia. Being in a dark room may ease the photophobia, but exercise may worsen the headache and associated symptoms. Clients who are taking medications specific for migraines should avoid St. John's Wort due to potential drug interactions.

An emergency department nurse understands that a 110-lb (50-kg) recent stroke victim will receive at least the minimum dose of recombinant tissue plasminogen activator (t-PA). What minimum dose will the client receive? -90 mg -50 mg -85 mg -45 mg

45 mg Explanation: The client is weighed to determine the dose of t-PA. Typically, two or more IV sites are established prior to administration of t-PA (one for the t-PA and the other for administration of IV fluids). The dosage for t-PA is 0.9 mg/kg, with a maximum dose of 90 mg. 50 kg X 0.9 mg= 45 mg dose

A patient is admitted via ambulance to the emergency room of a stroke center at 1:30 p.m. with symptoms that the patient said began at 1:00 p.m. Within 1 hour, an ischemic stroke had been confirmed and the doctor ordered tPA. The nurse knows to give this drug no later than what time?

4:00 p.m. Explanation: Tissue plasminogen activator (tPA) must be given within 3 hours after symptom onset. Therefore, since symptom onset was 1:00 pm, the window of opportunity ends at 4:00 pm.

A clinic nurse is caring for a client diagnosed with migraine headaches. During the client teaching session, the client questions the nurse regarding alcohol consumption. What would the nurse be correct in telling the client about the effects of alcohol? -Alcohol has an excitatory effect on the CNS. -Alcohol diminishes endorphins in the brain. -Alcohol causes vasodilation of the blood vessels. -Alcohol causes hormone fluctuations.

Alcohol causes vasodilation of the blood vessels. Explanation: Alcohol causes vasodilation of the blood vessels and may exacerbate migraine headaches. Alcohol has a depressant effect on the CNS. Alcohol does not cause hormone fluctuations, nor does it decrease endorphins (morphine-like substances produced by the body) in the brain.

A client recently had a stroke. Now the client has spasms in his/her hands, which is preventing a favorite hobby of knitting. The client is looking for a permanent solution to this problem. Which therapies would the nurse recommend? -Amitriptyline and splinting -Botulinum toxin type A and heat -Corticosteroids and acupuncture -Baclofen and stretching

Baclofen and stretching Explanation: Treatments for spasticity may include stretching, splinting (in select clients), and oral medications such as baclofen and tizanidine. Studies concerning splitting debate the effectiveness of this treatment. Botulinum toxin type A injected intramuscularly into wrist and finger muscles has been shown to be effective in reducing this spasticity but the effect is temporary, typically lasting 2 to 4 months. Amitriptyline is more effective for post-stroke pain and depression. Corticosteroids, heat therapy, and acupuncture are recommended for shoulder pain after a client has a stroke.

A patient who has had a previous stroke and is taking warfarin tells the nurse that he started taking garlic to help reduce his blood pressure. The nurse knows that garlic when taken together with warfarin will produce which type of interaction? May increase cerebral blood flow, causing migraine headaches Can greatly increase the international normalization ratio (INR), increasing the risk of bleeding No drug to drug interactions, may be taken together Can cause platelet aggregation, increasing the risk of blood clotting

Can greatly increase the international normalization ratio (INR), increasing the risk of bleeding Explanation: Taken together warfarin and garlic can greatly increase the INR, increasing the risk of bleeding

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? -Urinary output -Fluid and electrolyte balance -Cardiac and respiratory status -Seizure activity

Cardiac and respiratory status Explanation: Acute care begins with managing the ABC's. Patients may have difficulty keeping an open and clear airway secondary to decreased level of consciousness. Neurological assessment with close monitoring for signs of increased neurological deficit and seizure activity occurs next. Fluid and electrolyte balance must be controlled carefully, with the goal of adequate hydration to promote perfusion and decrease further brain damage.

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? -Small artery thrombosis -Cardiogenic emboli -Large artery thrombosis -Cerebral aneurysm

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

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? -Small artery thrombosis -Cerebral aneurysm -Large artery thrombosis -Cardiogenic emboli

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

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 -Nausea, vomiting, and profuse sweating -Difficulty breathing or swallowing -Tachycardia, tachypnea, and hypotension

Hemiplegia, seizures, and decreased level of consciousness Explanation: Spasm or occlusion of a cerebral vessel by a clot causes signs and symptoms similar to those of a stroke: hemiplegia, seizures, decreased level of consciousness, aphasia, hemiparesis, and increased focal symptoms. Nausea, vomiting, and profuse sweating suggest a delayed reaction to the contrast medium used in cerebral angiography. Difficulty breathing or swallowing may signal a hematoma in the neck. Tachycardia, tachypnea, and hypotension suggest internal hemorrhage.

A client diagnosed with a hemorrhagic stroke has been admitted to the neurologic ICU. The nurse knows that teaching for the client and family needs to begin as soon as the client is settled on the unit and will continue until the client is discharged. What will family education need to include? Risk factors for ischemic stroke How to differentiate between hemorrhagic and ischemic stroke How to correctly modify the home environment Techniques for adjusting the client's medication dosages at home

How to correctly modify the home environment Explanation: For a client with a hemorrhagic stroke, teaching addresses the use of assistive devices or modification of the home environment to help the client live with the disability. This is more important to the client's needs than knowing about risk factors for ischemic stroke. It is not necessary for the family to differentiate between different types of strokes. Medication regimens should never be altered without consultation.

A client is suspected of having had a stroke. Which is the initial diagnostic test for a stroke? -Electrocardiography -Noncontrast computed tomography -Transcranial Doppler studies -Carotid Doppler

Noncontrast computed tomography Explanation: The initial diagnostic test for a stroke is usually a noncontrast computed tomography (CT) scan. This should be performed within 25 minutes or less from the time the client presents to the ED to determine whether the event is ischemic or hemorrhagic (the category of stroke determines treatment). Further diagnostics include a carotid Doppler, electrocardiogram, and transcranial Doppler.

Nursing care during the immediate recovery period from an ischemic stroke should normally prioritize which intervention? -Initiating early mobilization -Maximizing partial pressure of carbon dioxide (PaCO2) -Administering hypertonic intravenous (IV) solution -Positioning the client to avoid intercranial pressure (ICP)

Positioning the client to avoid intercranial pressure (ICP) Explanation: Interventions during this period include measures to reduce ICP, such as administering an osmotic diuretic (e.g., mannitol) and positioning to avoid ICP, and handle secretions to avoid aspiration. Hypertonic IV solutions are not used unless sodium depletion is evident. PaCO2 must remain within an acceptable range, not maximized. Mobilization would take place after the immediate threat of increased ICP has passed.

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. -Place the wheelchair on the client's left side when transferring him into a wheelchair. -Anticipate the client will exhibit some degree of expressive or receptive aphasia. -Support the right arm with a sling or pillow to prevent subluxation.

Provide close supervision because of the client's impulsiveness and poor judgment. Explanation: The primary symptoms of a client who experiences a right-sided stroke are left-sided weakness, impulsiveness, and poor judgment. Aphasia is more commonly present when the dominant or left hemisphere is damaged. When a client has one-sided weakness, the nurse should place the wheelchair on the client's unaffected side. Because a right-sided stroke causes left-sided paralysis, the right side of the body should remain unaffected.

The nurse is caring for a client recovering from a carotid endarterectomy. Which finding indicates to the nurse that the client is experiencing hyperperfusion syndrome? Difficulty breathing Decreased blood pressure Severe unilateral headache Change in vision in one eye

Severe unilateral headache Explanation: Hyperperfusion syndrome occurs when cerebral vessel autoregulation fails. Arteries accustomed to diminished blood flow may be permanently dilated. Increased blood flow after endarterectomy coupled with insufficient vasoconstriction leads to capillary bed damage, edema, and hemorrhage. A unilateral headache that improves by sitting upright or standing is an intervention for this syndrome. Difficulty breathing is an indication of an incisional hematoma. A drop in blood pressure is an indication of postoperative hypotension. A change in vision in one eye could indicate the development of a stroke.

The nurse is participating in a health fair for stroke prevention. Which will the nurse say is a modifiable risk factor for ischemic stroke? -Thyroid disease -Advanced age -Social drinking -Smoking

Smoking Explanation: Modifiable risk factors for transient ischemic attack (TIA) and ischemic stroke include hypertension, type 1 diabetes, cardiac disease, smoking, and chronic alcoholism. Advanced age, gender, and race are nonmodifiable risk factors for stroke.

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

The day the patient has the stroke Explanation: Although rehabilitation begins on the day the patient has the stroke, the process is intensified during convalescence and requires a coordinated team effort.

A woman has been brought to the emergency department (ED) by her distraught husband who believes that she has had a stroke. A rapid assessment by the care team confirms that the husband's suspicions are likely accurate, and the woman is being screened for the possible administration of recombinant tissue plasminogen activator (r tPA). Which of the following factors would contraindicate the use of tPA? The woman's stroke has a hemorrhagic etiology. The woman has hypertension and type 1 diabetes. The woman is older than 80 years of age. The woman has previously had a stroke.

The woman's stroke has a hemorrhagic etiology. Explanation: tPA is contraindicated in hemorrhagic stroke because it would greatly exacerbate cerebral bleeding. Older age, previous stroke, hypertension, and diabetes do not necessarily contraindicate the use of tPA.

A nurse is teaching a community class that those experiencing symptoms of ischemic stroke need to enter the medical system early. The primary reason for this is which of the following? -A ruptured intracranial aneurysm must quickly be repaired. -A ruptured arteriovenous malformation will cause deficits until it is stopped. -Thrombolytic therapy has a time window of only 3 hours. -Intracranial pressure is increased by a space-occupying bleed.

Thrombolytic therapy has a time window of only 3 hours. Explanation: Currently approved thrombolytic therapy for ischemic strokes has a treatment window of only 3 hours after the onset of symptoms. Urgency is needed on the part of the public for rapid entry into the medical system. The other three choices are related to hemorrhagic strokes.

If warfarin is contraindicated as a treatment for stroke, which medication is the best option? -aspirin -Dipyridamole -Ticlodipine -Clopidogrel

aspirin Explanation: If warfarin is contraindicated, aspirin is the best option, although other medications may be used if both are contraindicated.

If warfarin is contraindicated as a treatment for stroke, which medication is the best option? -Clopidogrel -Dipyridamole -Ticlodipine -aspirin

aspirin Explanation: If warfarin is contraindicated, aspirin is the best option, although other medications may be used if both are contraindicated.

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

cardio embolic Explanation: Ischemic strokes are further divided into five subtypes, according to a mechanism-based classification system: large-artery thrombotic strokes (representing 20% of ischemic strokes); small, penetrating artery thrombotic strokes (25%); cardio embolic strokes (20%); cryptogenic strokes (strokes that cannot be attributed to any specific cause) (30%); and "other" (5%). Large-artery thrombotic strokes are caused by atherosclerotic plaques in the large blood vessels of the brain. Thrombus formation and occlusion can occur at the site of the atherosclerosis and result in ischemia and infarction (tissue death). Small, penetrating artery thrombotic strokes that affect one or more vessels and cause reduced blood flow are the most common type of ischemic stroke, typically caused by longstanding hypertension, hyperlipidemia, or diabetes. 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. The last two classifications of ischemic strokes are cryptogenic strokes, which have no identified cause, and strokes from other causes, such as illicit drug use (cocaine), coagulopathies, migraine, or spontaneous dissection of the carotid or vertebral arteries.

A physician has ordered home health and physical therapy for an older adult who will be discharged home following an acute stroke. The nurse's discharge teaching should include instructions about:

reporting specific signs and symptoms to the physician, discharge medications, and dietary concerns. Explanation: The nurse should tell the client what signs and symptoms to report to the physician, what medications he is being discharged with and how to take them, and what dietary changes he needs to implement. The nurse shouldn't instruct the client to call the home health nurse with all questions because certain situations or concerns require physician intervention. The nurse shouldn't encourage the client to avoid social activity; isolation may result in depression. Although effects of a stroke don't always reverse, the nurse should encourage the client to be as independent as possible. The physical therapist will provide information on exercises the client can do at home.

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? -severe exploding headache -difficulty finding appropriate words -slurred speech -left-sided weakness

severe exploding headache Explanation: A hemorrhagic stroke is often characterized by a severe headache (commonly described as the "worst headache ever") or as "exploding." Weakness and speech issues are more commonly associated with an ischemic stroke.

A client has a 12-year history of cluster headaches. After the client describes the characteristics of the head pain, the nurse begins to discuss its potential causes. What would the nurse indicate that the origin of the headaches is: -vasodilating agents. -unknown. -endocrine. -muscular.

unknown. Explanation: Although cluster headaches can be triggered by vasodilating agents, the cause of cluster headaches is unknown.

A client has recently begun mobilizing during the recovery from an ischemic stroke. To protect the client's safety during mobilization, which action(s) will the nurse perform? Select all that apply. -Avoid mobilizing in the early morning or late evening. -Ensure that the family members do not participate in mobilization. -Have a colleague follow closely with a wheelchair. -Monitor for standing balance. -Support the full-body weight with a waist belt during ambulation.

-Have a colleague follow closely with a wheelchair. -Monitor for standing balance. Explanation: Prior to mobilization, the client should be assessed for standing balance during mobilization. During mobilization, a chair or wheelchair should be readily available in case the client suddenly becomes fatigued or feels dizzy. The family should be encouraged to participate, as appropriate, and the nurse should not have to support the client's full body weight. Morning and evening activities are not necessarily problematic.

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. -Use a well-lighted room for assessments every 2 hours. -Avoid any activities that cause a Valsalva maneuver. -Report changes in neurologic status as soon as a worsening trend is identified. -Maintain the head of the bed at 30 degrees. -Follow the healthcare provider's orders to increase fluid volume.

-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. Explanation: Cerebral aneurysm precautions are implemented for the patient with a diagnosis of aneurysm to provide a nonstimulating environment, prevent increases in intracranial pressure, and prevent further bleeding. The patient is placed on bed rest in a quiet, nonstressful environment, because activity, pain, and anxiety are thought to elevate the blood pressure, which may increase the risk for bleeding. The head of the bed is elevated 30 degrees to promote venous drainage and decrease intracranial pressure. Any activity that suddenly increases the blood pressure or obstructs venous return is avoided. This includes the Valsalva maneuver, straining, forceful sneezing, pushing oneself up in bed and acute flexion or rotation of the head and neck (which compromises the jugular veins). Stool softeners and mild laxatives are prescribed to prevent constipation, which can cause an increase in intracranial pressure. Dim lighting is helpful for photophobia. Increasing fluid volume does not affect brain bleeding.

The nurse provides diet-related advice to a client who experienced a cerebrovascular accident (CVA) and is now having difficulty swallowing. Which food choice(s) should the nurse suggest to the client to reduce the potential for aspiration? Select all that apply. -chewy meats -thickened commercial beverages -cold foods -dry or crisp foods -peanut butter on bread

-cold foods -thickened commercial beverages Explanation: A client who experiences a CVA may have difficulty swallowing (i.e., dysphagia), which increases the risk for aspiration. To address this safety issue, there are several food choices that can be recommended by the nurse. These foods include thickened beverages, which are easiest to swallow. Another choice that is appropriate for this client is cold foods because they stimulate swallowing. Dry or crispy foods in addition to chewy meats are more likely to cause choking; therefore, they should be avoided. Additionally, peanut butter and bread is also a choking hazard; therefore, this food choice should not be recommended by the nurse.

The nurse is preparing to administer tissue plasminogen activator (t-PA) to a patient who weighs 132 lb. The order reads 0.9 mg/kg t-PA. The nurse understands that 10% of the calculated dose is administered as an IV bolus over 1 minute, and the remaining dose (90%) is administered IV over 1 hour via an infusion pump. How many milligrams IV bolus over 1 minute will the nurse initially administer?

5.4 Explanation: The patient is weighed to determine the dose of t-PA. Typically two or more IV sites are established prior to administration of t-PA (one for the t-PA and the other for administration of IV fluids). The dosage for t-PA is 0.9 mg/kg, with a maximum dose of 90 mg. Of the calculated dose, 10% is administered as an IV bolus over 1 minute. The remaining dose (90%) is administered IV over 1 hour via an infusion pump. First, the nurse must convert the patient's weight to kilograms (132/2.2 = 60 kg), then multiply 0.9 mg × 60 kg = 54 mg. Next, the nurse figure out that 10% of 54 mg is 5.4 (54 ×.10). The nurse will initially administer 5.4 mgs IV bolus over 1 minute.

A nurse is teaching a community group about modifiable and nonmodifiable risk factors for ischemic strokes. Which of the following is a risk factor that cannot be modified? -Atrial fibrillation -Obesity -Advanced age -Hypertension

Advanced age Explanation: Modifiable risk factors for ischemic stroke include hypertension, atrial fibrillation, hyperlipidemia, diabetes mellitus, smoking, asymptomatic carotid stenosis, obesity, and excessive alcohol consumption. Advanced age is a nonmodifiable risk factor.

A clinic nurse is caring for a client diagnosed with migraine headaches. During the client teaching session, the client questions the nurse regarding alcohol consumption. What would the nurse be correct in telling the client about the effects of alcohol? -Alcohol causes hormone fluctuations. -Alcohol causes vasodilation of the blood vessels. -Alcohol diminishes endorphins in the brain. -Alcohol has an excitatory effect on the CNS.

Alcohol causes vasodilation of the blood vessels. Explanation: Alcohol causes vasodilation of the blood vessels and may exacerbate migraine headaches. Alcohol has a depressant effect on the CNS. Alcohol does not cause hormone fluctuations, nor does it decrease endorphins (morphine-like substances produced by the body) in the brain.

A clinic nurse is caring for a client diagnosed with migraine headaches. During the client teaching session, the client questions the nurse regarding alcohol consumption. What would the nurse be correct in telling the client about the effects of alcohol? -Alcohol causes vasodilation of the blood vessels. -Alcohol diminishes endorphins in the brain. -Alcohol causes hormone fluctuations. -Alcohol has an excitatory effect on the CNS.

Alcohol causes vasodilation of the blood vessels. Explanation: Alcohol causes vasodilation of the blood vessels and may exacerbate migraine headaches. Alcohol has a depressant effect on the CNS. Alcohol does not cause hormone fluctuations, nor does it decrease endorphins (morphine-like substances produced by the body) in the brain.

A clinic nurse is caring for a client diagnosed with migraine headaches. During the client teaching session, the client questions the nurse regarding alcohol consumption. What would the nurse be correct in telling the client about the effects of alcohol? -Alcohol causes vasodilation of the blood vessels. -Alcohol has an excitatory effect on the CNS. -Alcohol causes hormone fluctuations. -Alcohol diminishes endorphins in the brain.

Alcohol causes vasodilation of the blood vessels. Explanation: Alcohol causes vasodilation of the blood vessels and may exacerbate migraine headaches. Alcohol has a depressant effect on the CNS. Alcohol does not cause hormone fluctuations, nor does it decrease endorphins (morphine-like substances produced by the body) in the brain.

A clinic nurse is caring for a client diagnosed with migraine headaches. During the client teaching session, the client questions the nurse regarding alcohol consumption. What would the nurse be correct in telling the client about the effects of alcohol? -Alcohol causes vasodilation of the blood vessels. -Alcohol has an excitatory effect on the CNS. -Alcohol diminishes endorphins in the brain. -Alcohol causes hormone fluctuations.

Alcohol causes vasodilation of the blood vessels. Explanation: Alcohol causes vasodilation of the blood vessels and may exacerbate migraine headaches. Alcohol has a depressant effect on the CNS. Alcohol does not cause hormone fluctuations, nor does it decrease endorphins (morphine-like substances produced by the body) in the brain.

The nurse is taking care of a client with a headache. The nurse can take which measure to assist the client in reducing the pain associated with the headache? -Apply warm or cool cloths to the forehead or back of the neck. -Use pressure-relieving pads or a similar type of mattress. -Encouraging the client to participate in stimulating activities. -Administer prescribed medications when pain intensifies.

Apply warm or cool cloths to the forehead or back of the neck. Explanation: A method to reduce pain is to apply warm (or cool) cloths to the forehead or back of the neck. Warmth promotes vasodilation; cool reduces blood flow. Prescribed medications should be administered as early as possible, not held until pain intensifies. The client should avoid overly stimulating activities and instead provide distraction through soft, soothing music, or guided imagery. Pressure-relieving pads or a mattress would not significantly reduce this type of pain.

The nurse is taking care of a client with a headache. The nurse can take which measure to assist the client in reducing the pain associated with the headache? -Encouraging the client to participate in stimulating activities. -Administer prescribed medications when pain intensifies. -Use pressure-relieving pads or a similar type of mattress. -Apply warm or cool cloths to the forehead or back of the neck.

Apply warm or cool cloths to the forehead or back of the neck. Explanation: A method to reduce pain is to apply warm (or cool) cloths to the forehead or back of the neck. Warmth promotes vasodilation; cool reduces blood flow. Prescribed medications should be administered as early as possible, not held until pain intensifies. The client should avoid overly stimulating activities and instead provide distraction through soft, soothing music, or guided imagery. Pressure-relieving pads or a mattress would not significantly reduce this type of pain.

The nurse is reviewing the medication administration record of a client who possesses numerous risk factors for stroke. Which of the client's medications presents the greatest potential for reducing the risk of stroke? -Calcium carbonate 1,000 mg PO b.i.d. -Lorazepam 1 mg SL b.i.d. PRN -Naproxen 250 PO b.i.d. -Aspirin 81 mg PO o.d.

Aspirin 81 mg PO o.d. Explanation: Research findings suggest that low-dose aspirin may lower the risk of stroke in women who are at risk. Naproxen, lorazepam, and calcium supplements do not have this effect.

A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? -Phenytoin -Methyldopa -Dexamethasone -Heparin sodium

Heparin sodium Explanation: Administering heparin, an anticoagulant, could increase the bleeding associated with hemorrhagic stroke. Therefore, the nurse should question this order to prevent additional hemorrhage in the brain. In a client with hemorrhagic stroke, the healthcare provider may use dexamethasone (Decadron) to decrease cerebral edema and pressure, methyldopa (Aldomet) to reduce blood pressure, and phenytoin (Dilantin) to prevent seizures.

A nurse is planning discharge for a client who experienced right-sided weakness caused by a stroke. During his hospitalization, the client has been receiving physical therapy, occupational therapy, and speech therapy daily. The family voices concern about rehabilitation after discharge. How should the nurse intervene? Inform the case manager of the family's concern and provide information about the client's current clinical status so appropriate resources can be provided after discharge. The nurse should do nothing because she is responsible only for inpatient care. Contact the appropriate agencies so that they can provide care after discharge. Suggest that the family members speak with the physician about their concerns.

Inform the case manager of the family's concern and provide information about the client's current clinical status so appropriate resources can be provided after discharge. Explanation: As the coordinator of care, the nurse must assess the client's needs and initiate referrals for the appropriate health team members to coordinate services needed after discharge. The nurse isn't responsible for contacting agencies to provide care after discharge. Simply providing information about the family's concerns doesn't ensure that services will be arranged for the client after discharge. Alerting the physician is helpful; however, that step doesn't ensure that the necessary services will be provided after discharge. Doing nothing is irresponsible.

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention? -Positioning the client to prevent airway obstruction -Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess -Keeping the client in one position to decrease bleeding -Maintaining the client in a quiet environment

Keeping the client in one position to decrease bleeding Explanation: The student nurse shouldn't keep the client in one position. She should carefully reposition the client often (at least every hour). The client needs to be positioned so that a patent airway can be maintained. Fluid administration must be closely monitored to prevent complications such as increased intracranial pressure. The client must be maintained in a quiet environment to decrease the risk of rebleeding.

A client is diagnosed with a right-sided stroke. The client is now experiencing hemianopsia. How might the nurse help the client manage the potential sensory and perceptional difficulties? -Place the client's clock on the affected side. -Place the client's extremities where the client can see them. -Approach the client on the side where vision is impaired. -Keep the lighting in the client's room low.

Place the client's extremities where the client can see them. Explanation: The client with homonymous hemianopsia (loss of half of the visual field) turns away from the affected side of the body and tends to neglect that side and the space on that side; this is called amorphosynthesis. In such instances, the client cannot see food on half of the tray, and only half of the room is visible. It is important for the nurse to remind the client constantly of the other side of the body, to maintain alignment of the extremities, and if possible, to place the extremities where the client can see them. Clients with a decreased field of vision should be approached on the side where visual perception is intact. All visual stimuli (clock, calendar, and television) should be placed on this side. The client can be taught to turn the head in the direction of the defective visual field to compensate for this loss. Increasing the natural or artificial lighting in the room and providing eyeglasses are important in increasing vision. There is no reason to keep the lights dim.

After a subarachnoid hemorrhage, the client's laboratory results indicate a serum sodium level of less than 126 mEq/L. What is the nurse's most appropriate action? -Facilitate testing for hypothalamic dysfunction. -Prepare to administer 3% NaCl by IV as prescribed. -Administer a bolus of normal saline as prescribed. -Prepare the client for thrombolytic therapy as prescribed.

Prepare to administer 3% NaCl by IV as prescribed. Explanation: The client may be experiencing syndrome of inappropriate antidiuretic hormone (SIADH) or cerebral salt-wasting syndrome. The treatment most often is the use of IV hypertonic 3% saline. A normal saline bolus would exacerbate the problem and there is no indication for tests of hypothalamic function or thrombolytic therapy.

The nurse is caring for a client recovering from a carotid endarterectomy. Which finding indicates to the nurse that the client is experiencing hyperperfusion syndrome? Difficulty breathing Severe unilateral headache Change in vision in one eye Decreased blood pressure

Severe unilateral headache Explanation: Hyperperfusion syndrome occurs when cerebral vessel autoregulation fails. Arteries accustomed to diminished blood flow may be permanently dilated. Increased blood flow after endarterectomy coupled with insufficient vasoconstriction leads to capillary bed damage, edema, and hemorrhage. A unilateral headache that improves by sitting upright or standing is an intervention for this syndrome. Difficulty breathing is an indication of an incisional hematoma. A drop in blood pressure is an indication of postoperative hypotension. A change in vision in one eye could indicate the development of a stroke.

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? -Slow, cautious behavior -Aphasia -Spatial-perceptual deficits -Altered intellectual ability

Spatial-perceptual deficits Explanation: Clients with right hemispheric stroke exhibit partial perceptual deficits, left visual field deficit, and paralysis with weakness on the left side of the body. Left hemispheric damage causes aphasia, slow, cautious behavior, and altered intellectual ability.

A client recovering from a stroke has severe shoulder pain from subluxation of the shoulder. To prevent further injury and pain, the nurse caring for this client is aware of what principle of care? Elevation of the arm and hand can lead to further complications associated with edema. The client should be fitted with a cast because use of a sling should be avoided due to adduction of the affected shoulder. The client should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder. Passively exercising the affected extremity is avoided in order to minimize pain.

The client should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder. Explanation: To prevent shoulder pain, the nurse should never lift a client by the flaccid shoulder or pull on the affected arm or shoulder. The client is taught how to move and exercise the affected arm/shoulder through proper movement and positioning. The client is instructed to interlace the fingers, place the palms together, and push the clasped hands slowly forward to bring the scapulae forward; he or she then raises both hands above the head. This is repeated throughout the day. The use of a properly worn sling when the client is out of bed prevents the paralyzed upper extremity from dangling without support. Range-of-motion exercises are still vitally important in preventing a frozen shoulder and ultimately atrophy of subcutaneous tissues, which can cause more pain. Elevation of the arm and hand is also important in preventing dependent edema of the hand.

A client who has experienced an ischemic stroke has been admitted to the medical unit. The client's family is adamant that the client remain on bed rest to hasten recovery and to conserve energy. What principle of care should inform the nurse's response to the family? The client should mobilize as soon as physically able. Lack of mobility will greatly increase the client's risk of stroke recurrence. To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks. The client should remain on bed rest until the client expresses a desire to mobilize.

The client should mobilize as soon as physically able. Explanation: As soon as possible, the client is assisted out of bed and an active rehabilitation program is started. Delaying mobility causes complications, but not necessarily stroke recurrence. Mobility should not be withheld until the client initiates.

When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke? -After the patient has passed the acute phase of the stroke -After the nurse has received the discharge -The day before the patient is discharged -The day the patient has the stroke

The day the patient has the stroke Explanation: Although rehabilitation begins on the day the patient has the stroke, the process is intensified during convalescence and requires a coordinated team effort.

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

The day the patient has the stroke Explanation: Although rehabilitation begins on the day the patient has the stroke, the process is intensified during convalescence and requires a coordinated team effort.

A woman has been brought to the emergency department (ED) by her distraught husband who believes that she has had a stroke. A rapid assessment by the care team confirms that the husband's suspicions are likely accurate, and the woman is being screened for the possible administration of recombinant tissue plasminogen activator (r tPA). Which of the following factors would contraindicate the use of tPA? The woman has hypertension and type 1 diabetes. The woman has previously had a stroke. The woman's stroke has a hemorrhagic etiology. The woman is older than 80 years of age.

The woman's stroke has a hemorrhagic etiology. Explanation: tPA is contraindicated in hemorrhagic stroke because it would greatly exacerbate cerebral bleeding. Older age, previous stroke, hypertension, and diabetes do not necessarily contraindicate the use of tPA.

A woman has been brought to the emergency department (ED) by her distraught husband who believes that she has had a stroke. A rapid assessment by the care team confirms that the husband's suspicions are likely accurate, and the woman is being screened for the possible administration of recombinant tissue plasminogen activator (r tPA). Which of the following factors would contraindicate the use of tPA? The woman's stroke has a hemorrhagic etiology. The woman is older than 80 years of age. The woman has hypertension and type 1 diabetes. The woman has previously had a stroke.

The woman's stroke has a hemorrhagic etiology. Explanation: tPA is contraindicated in hemorrhagic stroke because it would greatly exacerbate cerebral bleeding. Older age, previous stroke, hypertension, and diabetes do not necessarily contraindicate the use of tPA.

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?

Three hours Explanation: 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.

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? -One hour -Three hours -Six hours -Two hours

Three hours Explanation: 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.

A nurse is teaching a community class that those experiencing symptoms of ischemic stroke need to enter the medical system early. The primary reason for this is which of the following? -A ruptured arteriovenous malformation will cause deficits until it is stopped. -Intracranial pressure is increased by a space-occupying bleed. -Thrombolytic therapy has a time window of only 3 hours. -A ruptured intracranial aneurysm must quickly be repaired.

Thrombolytic therapy has a time window of only 3 hours. Explanation: Currently approved thrombolytic therapy for ischemic strokes has a treatment window of only 3 hours after the onset of symptoms. Urgency is needed on the part of the public for rapid entry into the medical system. The other three choices are related to hemorrhagic strokes.

A client diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy (CEA). The nurse explains that this procedure will be done for what purpose? -To determine the cause of the TIA -To remove atherosclerotic plaques blocking cerebral flow -To decrease cerebral edema -To prevent seizure activity that is common following a TIA

To remove atherosclerotic plaques blocking cerebral flow Explanation: The main surgical procedure for select clients with TIAs is carotid endarterectomy, the removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in clients with occlusive disease of the extracranial arteries. An endarterectomy does not decrease cerebral edema, prevent seizure activity, or determine the cause of a TIA.

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

cardio embolic Explanation: Ischemic strokes are further divided into five subtypes, according to a mechanism-based classification system: large-artery thrombotic strokes (representing 20% of ischemic strokes); small, penetrating artery thrombotic strokes (25%); cardio embolic strokes (20%); cryptogenic strokes (strokes that cannot be attributed to any specific cause) (30%); and "other" (5%). Large-artery thrombotic strokes are caused by atherosclerotic plaques in the large blood vessels of the brain. Thrombus formation and occlusion can occur at the site of the atherosclerosis and result in ischemia and infarction (tissue death). Small, penetrating artery thrombotic strokes that affect one or more vessels and cause reduced blood flow are the most common type of ischemic stroke, typically caused by longstanding hypertension, hyperlipidemia, or diabetes. 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. The last two classifications of ischemic strokes are cryptogenic strokes, which have no identified cause, and strokes from other causes, such as illicit drug use (cocaine), coagulopathies, migraine, or spontaneous dissection of the carotid or vertebral arteries.