Chapter 38: Caring for Clients with Cerebrovascular Disorders

A nurse is helping a client understand the cause of ischemic stroke. Which statements might be included in this discussion? Select all that apply.

"Your stroke occurred because a blood clot got lodged in an artery that carries blood to your brain." The type of stroke you had occurs in 80% of the people who have a stroke." Ischemic strokes occur when a thrombus or embolus obstructs an artery carrying blood to the brain. About 80% of strokes are of the ischemic variety.

A patient is in the acute phase of an ischemic stroke. How long does the nurse know that this phase may last?

1 to 3 days The acute phase of an ischemic stroke may last 1 to 3 days, but ongoing monitoring of all body systems is essential as long as the patient requires care.

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. 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 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?

Advanced age Modifiable risk factors for ischemic stroke include hypertension, atrial fibrillation, hyperlipidemia, diabetes mellitus, smoking, asymptomatic carotid stenosis, obesity, and excessive alcohol consumption. Nonmodifiable risk factors include advanced age, gender, and race.

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?

An obese woman with a history of atrial fibrillation and type 2 diabetes 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.

The nurse is taking care of a client with a headache. In addition to administering medications, the nurse takes 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. Warmth promotes vasodilation; cool stimuli reduce blood flow.

The nurse is reviewing the medication administration record of a female client who possesses numerous risk factors for stroke. Which of the woman's medications carries the greatest potential for reducing her risk of stroke?

Aspirin 81 mg PO o.d. 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.

The nurse is caring for a client who is known to be at risk for cardiogenic embolic strokes. What dysrhythmia does this client most likely have?

Atrial fibrillation 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 diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse?

Call the health care provider immediately. A headache may be an indication that the aneurysm is leaking. The nurse should notify the health care provider immediately. The health care provider will decide whether administration of an analgesic is indicated. Informing the nurse manager is not necessary. Sitting with the client is appropriate, once the health care provider has been notified of the change in the client's condition.

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?

Cardiac and respiratory status 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?

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

A community health nurse is conducting a workshop for unlicensed care providers who work in a chain of long-term care facilities. The nurse is teaching the participants about the signs and symptoms of stroke. What signs and symptoms should the nurse identify? Select all that apply.

Confusion Sudden numbness Visual disturbances The most common symptoms of stroke include numbness or weakness of the face, arm, or leg, especially on one side of the body; confusion or change in mental status; trouble speaking or understanding speech; visual disturbances; difficulty walking, dizziness, or loss of balance or coordination; and sudden, severe headache.

A client diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for what purpose?

To remove atherosclerotic plaques blocking cerebral flow 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 client reports light-headedness, speech disturbance, and left-sided weakness that have lasted for several hours. In the examination, an abnormal sound is auscultated in an artery leading to the brain. What is the term for the auscultated discovery?

bruit A neurologic examination during an attack reveals neurologic deficits. Auscultation of the artery may reveal a bruit (abnormal sound caused by blood flowing over a rough surface within one or both carotid arteries). The term for the auscultated discovery is "bruit."

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 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.

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. 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 migraine headaches and is frustrated over how these headaches impact lifestyle. What would the nurse indicate to the client is the origin of migraines?

vascular Migraine headaches, which are recurrent and severe and last for a day or more, have a vascular origin.

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?

Absolute bed rest in a quiet, nonstimulating environment 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 client with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the client's cardiac and neurologic status, the nurse monitors the client for signs of what complication?

Bleeding Bleeding is the most common side effect of t-PA administration, and the client is closely monitored for any bleeding. Septicemia, pain, and seizures are much less likely to result from thrombolytic therapy.

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?

Disturbed sensory perception 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?

Form words that are understandable or comprehend spoken words 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 stroke victim is experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe?

Frontal If damage has occurred to the frontal lobe, learning capacity, memory, or other higher cortical intellectual functions may be impaired. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and a lack of motivation.

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?

Frustration around changes in function and communication 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 a nonmodifiable risk factor for ischemic stroke?

Gender Nonmodifiable risk factors include gender, age, and race. Modifiable risk factors include atrial fibrillation, hyperlipidemia, and smoking.

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 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 healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question?

Heparin sodium 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.

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:

Hypertension 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 people newly diagnosed with migraine headaches. What information should the nurse include in the educational session? Select all that apply.

Keep a food diary. Maintain a headache diary. 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.

What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke?

Left visual field deficit 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 nurse is caring for a client diagnosed with a hemorrhagic stroke. When creating this client's plan of care, what goal should be prioritized?

Maintain and improve cerebral tissue perfusion. Each of the listed goals is appropriate in the care of a client recovering from a stroke. However, promoting cerebral perfusion is a priority physiologic need, on which the client's survival depends.

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?

Prepare to administer 3% NaCl by IV as prescribed. 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.

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 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 administering intravenous tissue plasminogen activator (tPA) to a client having a stroke. Which criteria must be met before administering the agent? Select all that apply.

onset of stroke within 3 hours of initiation of therapy normal prothrombin (PT) and partial thromboplastin (PTT) times Protocol guidelines require its use intravenously within the first 3 hours of the event; after that, its detriments may outweigh its benefits. The most common risk associated with tPA is bleeding; therefore, normal PT and OTT times are inclusion criteria for receiving the agent. Tissue plasminogen activator is contraindicated in clients having a hemorrhagic stroke. Exclusion criteria includes serious head trauma in the past 3 months.

The nurse is participating in a health fair for stroke prevention. Which will the nurse say is a modifiable risk factor for ischemic stroke?

Smoking 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.

The nurse is preparing discharge teaching for a patient who is being discharged after hospitalization for a hemorrhagic stroke. What should be included in the discharge teaching for this patient?

Take antihypertensive medication as ordered. The patient and family are provided with information that will enable them to cooperate with the care and restrictions required during the acute phase of hemorrhagic stroke and to prepare them to return home. Patient and family teaching includes information about the causes of hemorrhagic stroke and its possible consequences. Symptoms of hydrocephalus include gradual onset of drowsiness and behavioral changes. Hypertension is the most serious risk factor, suggesting that appropriate antihypertensive treatment is essential for a patient being discharged. Seizure activity is not normal; complaints of a serious headache should be called to the health care provider before any medication is taken. Drowsiness is not normal.

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?

impaired cerebral circulation 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 is concerned about having had intermittent cluster headaches over the last year. While several medications can be prescribed for the treatment of cluster headaches, which routes are preferred for medication administration of these drugs? Select all that apply.

inhaled intramuscular Injected drugs are preferred because they are absorbed more rapidly than those administered by the oral route.

The pathophysiology of an ischemic stroke involves the ischemic cascade, which includes the following steps:1. Change in pH2. Blood flow decreases3. A switch to anaerobic respiration <wbr />4. Membrane pumps fail5. Cells cease to function6. Lactic acid is generatedPut these steps in order in which they occur.

236145 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 client is diagnosed with a right-sided stroke. The client is now experiencing hemianopsia. How might the nurse help the client manage her potential sensory and perceptional difficulties?

Place the client's extremities where she can see them. 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.

A nurse in the ICU is providing care for a client who has been admitted with a hemorrhagic stroke. The nurse is performing frequent neurologic assessments and observes that the client is becoming progressively more drowsy over the course of the day. What is the nurse's best response to this assessment finding?

Report this to the health care provider as a possible sign of clinical deterioration. Alteration in LOC often is the earliest sign of deterioration in a client with a hemorrhagic stroke. Drowsiness and slight slurring of speech may be early signs that the LOC is deteriorating. This finding is unlikely to be the result of metabolic changes and it is not expected. Stimulating a client with an acute stroke is usually contraindicated.

A client who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurse's care of this client?

The client should be approached on the side where visual perception is intact. Clients with decreased field of vision should first be approached on the side where visual perception is intact. All visual stimuli should be placed on this side. The client can and should be taught to turn the head in the direction of the defective visual field to compensate for this loss. The nurse should constantly remind the client of the other side of the body and should later stand at a position that encourages the client to move or turn to visualize who and what is in the room.

A patient having an acute stroke with no other significant medical disorders has a blood glucose level of 420 mg/dL. What significance does the hyperglycemia have for this patient?

This is significant for poor neurologic outcomes. Hyperglycemia has been associated with poor neurologic outcomes in acute stroke and should be treated if the blood glucose is above 140 mg/dL (Summers et al., 2009).

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?

cardio embolic 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 client presents to the ED with a stiff neck, headache, and visual disturbances. The client is lethargic and has weakness on the left side. A CT scan reveals a ruptured aneurysm with a slow leak. The client's significant other is very concerned about the status and prognosis of the client. Based on the Hunt-Hess Scale, what grade will the physician most likely assign to the client that will assist in discussing the client's prognosis with the family?

grade III Grade III classification criteria include lethargy or confusion and minor focal deficits such as hemiparesis (weakness on one side). The client's symptoms are consistent with grade III classification.

A client reports intermittent cluster headaches over the last year. The nurse reviews with the client interventions to alleviate the symptoms associated with headaches. The plan of care would include all except:

listening to a relaxation tape. Clients with migraine or cluster headaches are not receptive to relaxation tapes as an approach to alleviate symptoms. Sensory stimuli decrease pain tolerance. Warmth promotes vasodilation; cool reduces blood flow. Medications work best to relieve symptoms if taken as soon as possible.