Chapter 57 Stroke

A patient admitted with possible stroke has been aphasic for 3 hours, and his current blood pressure (BP) is 174/94 mm Hg. Which order by the health care provider should the nurse question?

Start a labetalol drip to keep BP less than 140/90 mm Hg

The female patient has been brought to the emergency department complaining of the most severe headache of her life. Which type of stroke should the nurse anticipate?

Subarachnoid hemorrhage

The nurse is teaching a senior citizen's group about signs and symptoms of a stroke. Which statement by the nurse would provide accurate information?

"Call 911 immediately if a person develops slurred speech or difficulty speaking."

After receiving change-of-shift report on the following four patients, which patient should the nurse see first?

A 60-year-old patient with right-sided weakness who has an infusion of tPA prescribed

Which sensory-perceptual deficit is associated with left-sided stroke (right hemiplegia)?

Slow and possibly fearful performance of tasks

The nurse in a primary care provider's office is assessing several patients today. Which patient is most at risk for a stroke?

A 72-yr-old male patient who has hypertension and diabetes mellitus and smokes tobacco

A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider?

The patient has atrial fibrillation and takes warfarin (Coumadin)

A male patient who has right-sided weakness after a stroke is making progress in learning to use the left hand for feeding and other activities. The nurse observes that when the patient's wife is visiting, she feeds and dresses him. Which nursing diagnosis is most appropriate for the patient?

Disabled family coping related to inadequate understanding by the patient'

A patient with a left-brain stroke suddenly bursts into tears when family members visit. The nurse should

Teach the family that emotional outbursts are common after strokes

Which stroke risk factor for a 48-year-old patient in the clinic is most important for the nurse to address?

The patient's usual blood pressure (BP) is 170/94 mm Hg

A 70-year-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first?

Check the respiratory rate and effort

Which intervention is most appropriate when communicating with a patient with aphasia after a stroke?

Use simple, short sentences accompanied by visual cues to enhance comprehension

A 63-year-old patient who began experiencing right arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol?

Administer oxygen to keep O₂ saturation >95% Use National Institute of Health Stroke Scale to assess patient Obtain CT scan without contrast Infuse tissue plasminogen activator (tPA)

The nurse is caring for a patient who has been experiencing stroke symptoms for 60 minutes. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)?

Administer the prescribed short-acting insulin

A female patient has left-sided hemiplegia after an ischemic stroke 4 days earlier. How should the nurse promote skin integrity?

Alternate the patient's positioning between supine and side-lying

A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first?

Computed tomography (CT) scan

A patient with a stroke experiences facial drooping on the right side and right-sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find?

Difficulty comprehending instructions

The nurse would expect to find what clinical manifestation in a patient admitted with a left-sided stroke?

Impaired speech

A CT scan of a 68-yr-old male patient's head reveals that he has experienced a hemorrhagic stroke. What is the priority nursing intervention in the emergency department?

Maintenance of the patient's airway

When caring for a patient with a new right-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care?

Place needed objects on the patient's left side

The nurse is planning psychosocial support for the family of the patient who suffered a stroke. What factor will have the greatest impact on family coping?

Rehabilitation potential of the patient

Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness. Which patient problem do they determine has the highest priority for the patient?

Risk for aspiration related to inability to protect airway

The patient with diabetes mellitus had a right-sided stroke. Which nursing intervention should the nurse plan to provide for this patient?

Safety measures

The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting. Which assessment is of most concern to the nurse?

The patient has difficulty speaking

A patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin?

The patient reports that symptoms began with a severe headache

Which information about the patient who has had a subarachnoid hemorrhage is most important to communicate to the health care provider?

The patient's blood pressure (BP) is 90/50 mm Hg

The nurse is discharging a patient admitted with a transient ischemic attack (TIA). For which medications might the nurse expect to provide discharge instructions (select all that apply.)?

Ticlopidine Clopidogrel Dipyridamole Enteric-coated aspirin

A patient will attempt oral feedings for the first time after having a stroke. The nurse should assess the gag reflex and then

assist the patient into a chair

A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which response by the nurse is accurate?

"The obstructing plaque is surgically removed from inside an artery in the neck."

When providing care to the patient with an acute stroke, which duty can be delegated to the LPN/LVN?

Administer scheduled anticoagulant medications

A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the patient says, "I don't need the aspirin today. I don't have a fever." Which action should the nurse take?

Explain that the aspirin is ordered to decrease stroke risk

A patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will the nurse include in the plan of care?

Apply intermittent pneumatic compression stockings

A 74-yr-old man who has right-sided extremity paralysis related to a thrombotic stroke develops constipation. Which action should the nurse take first?

Arrange for several servings per day of cooked fruits and vegetables

A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours. The nurse will anticipate teaching the patient about

Aspirin

The nurse observes a student nurse assigned to initiate oral feedings for a 68-yr-old woman with an ischemic stroke. Which action by the student will require the nurse to intervene?

Assessing cranial nerves III, IV, and VI before attempting feeding

Several weeks after a stroke, a 50-year-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention should be planned to begin an effective bladder training program?

Assist the patient onto the bedside commode every 2 hours

A left-handed patient with left-sided hemiplegia has difficulty feeding himself. Which intervention should the nurse include in the plan of care?

Assist the patient to eat with the right hand

Which modifiable risk factor for stroke would be most important for the nurse to include when planning a community education program?

Hypertension

A female patient who had a stroke 24 hours ago has expressive aphasia. An appropriate nursing intervention to help the patient communicate is to

ask questions that the patient can answer with "yes" or "no."

After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual effects, the nurse anticipates teaching the patient about

oral low-dose aspirin therapy

For a patient who had a right hemisphere stroke, the nurse anticipates planning interventions to manage

risk for injury related to denial of deficits and impulsiveness

A patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously, and health records show a history of several transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for

tissue plasminogen activator (tPA) infusion

When teaching about clopidogrel (Plavix), the nurse will tell the patient with cerebral atherosclerosis

to call the health care provider if stools are tarry

During the change of shift report, a nurse is told that a patient has an occluded left posterior cerebral artery. The nurse will anticipate that the patient may have

visual deficits