Chapter 62- Management of Patients with Cerebrovascular Disorders

Which interventions would be recommended for a client with dysphagia? Select all that apply.

- Assist the client with meals. - Test the gag reflex before offering food or fluids. - Allow ample time to eat.

A client is following up after a visit to the emergency department where testing indicated that the client had suffered a transient ischemic attack. What lifestyle changes would the nurse include in teaching to prevent further reoccurrence? Select all that apply.

- Blood pressure control - Weight loss - Smoking cessation

Which are contraindications for the administration of tissue plasminogen activator (t-PA)? Select all that apply.

- Intracranial hemorrhage - Major abdominal surgery within 10 days

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

Which of the following, if left untreated, can lead to an ischemic stroke?

Atrial fibrillation

Which of the following is the most common side effect of tissue plasminogen activator (tPA)?

Bleeding

The provider diagnoses the patient as having had an ischemic stroke. The etiology of an ischemic stroke would include which of the following?

Cardiogenic emboli

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.

Which of the following is the chief cause of intracerebral hemorrhage (ICH)?

Uncontrolled hypertension

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

A nurse is providing care to a client who has had a stroke. Which symptoms are consistent with left-sided stroke?

mpulsive behavior, poor judgment, deficits in left visual fields

The nurse is caring for a client with aphasia. Which action will the nurse take when communicating with the client? Select all that apply.

- Pause between phrases - Use gestures when talking - Face the client when talking - Speak in a normal tone of voice

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. - Maintain the head of the bed at 30 degrees. - Avoid any activities that cause a Valsalva maneuver.

The nurse plays a critical role in the initial work-up of a patient with acute stroke symptoms. An immediate decision is to determine if the stroke is ischemic or hemorrhagic. Although there is overlap in some motor, sensory, and cognitive changes, hemorrhagic strokes can be identified by some specific signs. Which of the following signs are consistent with a hemorrhagic stroke? Select all that apply.

- Vomiting - Sudden, severe headache - Seizures

After a stroke, a client is admitted to the facility. The client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g. Which nursing intervention is a priority for this client?

Elevating the head of the bed to 30 degrees

Aneurysm rebleeding occurs most frequently during which time frame after the initial hemorrhage?

First 2 to 12 hours

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

Which is the most common motor dysfunction seen in clients diagnosed with stroke?

Hemiplegia

A nurse practitioner provides health teaching to a patient who has difficulty managing hypertension. This patient is at an increased risk of which type of stroke?

Intracerebral hemorrhage

Which is a contraindication for the administration of tissue plasminogen activator (t-PA)?

Intracranial hemorrhage

A client has experienced an ischemic stroke that has damaged the lower motor neurons of the brain. Which of the following deficits would the nurse expect during assessment?

Lack of deep tendon reflexes

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

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are:

Severe headache and early change in level of consciousness

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?

Severe unilateral headache

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?

Spatial-perceptual deficits

What nursing intervention is appropriate for a client with receptive aphasia?

Speak slowly and clearly.