Chapter 62: Management of Patients with Cerebrovascular Disorders - PrepU

A nurse is instructing the spouse of a client who suffered a stroke about the use of eating devices the client will be using. During the teaching, the spouse starts to cry and states, "One minute he is laughing, and the next he's crying; I just don't understand what's wrong with him." Which statement is the best response by the nurse? -"Emotional lability is common after a stroke, and it usually improves with time." -"You seem upset, and it may be hard for you to focus on the teaching, I'll come back later." -"This behavior is common in clients with stroke. Which does your spouse do more often? Laugh or cry?" -"You sound stressed; maybe using some stress management techniques will help."

"Emotional lability is common after a stroke, and it usually improves with time." This is the most therapeutic and informative response. Often, most relatives of clients with stroke handle the physical changes better than the emotional aspects of care. The family should be prepared to expect occasional episodes of emotional lability. The client may laugh or cry easily and may be irritable and demanding or depressed and confused. The nurse can explain to the family that the client's laughter does not necessarily connote happiness, nor does crying reflect sadness, and that emotional lability usually improves with time. The remaining responses are nontherapeutic and do not address the spouse's concerns.

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

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

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.

When communicating with a client who has sensory (receptive) aphasia, the nurse should: -allow time for the client to respond. -speak loudly and articulate clearly. -give the client a writing pad. -use short, simple sentences.

use short, simple sentences. Although sensory aphasia allows the client to hear words, it impairs the ability to comprehend their meaning. The nurse should use short, simple sentences to promote comprehension. Allowing time for the client to respond might be helpful but is less important than simplifying the communication. Because the client's hearing isn't affected, speaking loudly isn't necessary. A writing pad is helpful for clients with expressive, not receptive, aphasia.

A family member brings the client to the clinic for a follow-up visit after a stroke. The family member asks the nurse what he can do to decrease his chance of having another stroke. What would be the nurse's best answer? -"Have your heart checked regularly." -"Stop smoking as soon as possible." -"Take your prescribed medication to bring down your sodium levels." -"Eat a nutritious diet."

"Stop smoking as soon as possible." Smoking is a modifiable and highly significant risk factor for stroke. The significance of smoking, and the potential benefits of quitting, exceed the roles of sodium, diet, and regular medical assessments.

A patient is in the acute phase of an ischemic stroke. How long does the nurse know that this phase may last? -Up to 2 weeks -Up to 1 week -1 to 3 days -Up to 24 hours

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.

Which term refers to the failure to recognize familiar objects perceived by the senses? -Agnosia -Agraphia -Apraxia -Perseveration

Agnosia Auditory agnosia is failure to recognize significance of sounds. Agraphia refers to disturbances in writing intelligible words. Apraxia refers to an inability to perform previously learned purposeful motor acts on a voluntary basis. Perseveration is the continued and automatic repetition of an activity, word, or phrase that is no longer appropriate.

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

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

A client has experienced an ischemic stroke that has damaged the temporal (lateral and superior portions) lobe. Which of the following deficits would the nurse expect during assessment of this client? -Limited attention span and forgetfulness -Hemiplegia or hemiparesis -Lack of deep tendon reflexes -Auditory agnosia

Auditory agnosia Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia. 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 lack of motivation. Damage to motor neurons may cause hemiparesis, hemiplegia, and a change in reflexes.

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? -Checking stools for occult blood -Performing range-of-motion (ROM) exercises on the left side -Keeping skin clean and dry -Elevating the head of the bed to 30 degrees

Elevating the head of the bed to 30 degrees Because the client's gag reflex is absent, elevating the head of the bed to 30 degrees helps minimize the client's risk of aspiration. Checking the stools, performing ROM exercises, and keeping the skin clean and dry are important, but preventing aspiration through positioning is the priority.

How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tPA)? -Every 15 minutes -Every 30 minutes -Every 45 minutes -Every hour

Every 15 minutes Neurological assessment and vital signs (except temperature) should be taken every 15 minutes initially while the patient is receiving tPA infusion.

A client is receiving an IV infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To confirm that this drug is producing its therapeutic effect, the nurse should consider which finding most significant? -Decreased level of consciousness (LOC) -Elevated blood pressure -Increased urine output -Decreased heart rate

Increased urine output The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output. A decreased LOC and elevated blood pressure may indicate lack of therapeutic effectiveness. A decreased heart rate doesn't indicate that mannitol is effective.

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? -Limited attention span and forgetfulness -Visual agnosia -Lack of deep tendon reflexes -Auditory agnosia

Lack of deep tendon reflexes Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia. 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 lack of motivation. Damage to the lower motor neurons may cause decreased muscle tone, flaccid muscle paralysis, and a decrease in or loss of reflexes.

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) 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).

The geriatric advanced practice nurse (APN) is doing client teaching with a client who has had a cerebrovascular accident (CVA) and the client's family. One concern the APN addresses is a potential for falls related to the CVA and resulting muscle weakness. What would be most important for the APN to include in teaching related to this concern? -Leg exercises to strengthen muscle weakness. -Need for support group due to decreased self image related to restricted mobility. -Remove throw rugs and electrical cords from home environment. -Use of tripod cane.

Remove throw rugs and electrical cords from home environment. Client and family teaching is essential and focuses on the following points: Remove throw rugs, clutter, and electrical cords from the client's home environment to reduce the potential for falls. Although the other interventions may be appropriate, they are not as directly related to reducing fall risk.

A client on your unit is scheduled to have intracranial surgery in the morning. Which nursing intervention helps to avoid intraoperative complications, reduce cerebral edema, and prevent postoperative vomiting? -Restrict fluids before surgery. -Administer prescribed medications. -Administer preoperative sedation. -Administer an osmotic diuretic.

Restrict fluids before surgery. Before surgery, the nurse should restrict fluids to avoid intraoperative complications, reduce cerebral edema, and prevent postoperative vomiting. The nurse administers prescribed medications such as an anticonvulsant phenytoin, like Dilantin, to reduce the risk of seizures before and after surgery, an osmotic diuretic, and corticosteroids. Preoperative sedation is omitted.

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: -Spatial-perceptual deficits. -Left visual field deficit. -Right-sided paralysis. -Impulsive behavior.

Right-sided paralysis. 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.

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are: -Weakness on one side of the body and difficulty with speech -Severe headache and early change in level of consciousness -Foot drop and external hip rotation -Confusion or change in mental status

Severe headache and early change in level of consciousness The main presenting symptoms for ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body, confusion or change in mental status, and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Foot drop and external hip rotation can occur if a stroke victim is not turned or positioned correctly.

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 -Social drinking -Advanced age -Smoking

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.

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

Thrombolytic therapy for the treatment of an ischemic stroke should be initiated within how many hours of the onset of symptoms to obtain the best functional outcome? -3 hours -6 hours -9 hours -12 hours

3 hours Rapid diagnosis of stroke and initiation of thrombolytic therapy (within 3 hours) in clients with ischemic stroke lead to a decrease in the size of the stroke and an overall improvement in functional outcome after 3 months. Some scientific statements have endorsed its expanded use for up to 4.5 hours.

A client has experienced an ischemic stroke that has damaged the frontal lobe of his brain. Which of the following deficits does the nurse expect to observe during assessment? -Limited attention span and forgetfulness -Hemiplegia or hemiparesis -Lack of deep tendon reflexes -Visual and auditory agnosia

Limited attention span and forgetfulness Damage to the frontal lobe may impair learning capacity, memory, or other higher cortical intellectual functions. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and a lack of motivation. Damage to the motor neurons may cause hemiparesis, hemiplegia, and a change in reflexes. Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia.

A female client who reports recurring headaches, accompanied by increased irritability, photophobia, and fatigue is asked to track the headache symptoms and occurrence on a calendar log. Which is the best nursing rationale for this action? -Cluster headaches can cause severe debilitating pain. -Migraines often coincide with menstrual cycle. -Tension headaches are easier to treat. -Headaches are the most common type of reported pain.

Migraines often coincide with menstrual cycle. Changes in reproductive hormones as found during menstrual cycle can be a trigger for migraine headaches and may assist in the management of the symptoms. Cluster headaches can cause severe pain but are not the reason for tracking. Tension headaches can be managed but is not associated with a monthly calendar. Headaches are common but not the reason for tracking.

A client is admitted for evaluation of cerebral aneurysm. Which assessment finding is of greatest importance in prioritizing nursing care to this client? -Report of headache off and on for past month -No bowel movement since yesterday -Nausea -Frequent voiding

Nausea Nausea needs to be controlled to prevent vomiting, which can greatly increase the intracranial pressure and subsequently rupture the aneurysm. Report of headache for past month is significant to the evaluation at hand but should be addressed after the nausea has been controlled. Having no bowel movement since yesterday is not significant; although, every effort should be made to prevent constipation. Frequent voiding is expected especially with the use of osmotic diuretics.

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 -Prone -Supine -Semi-Fowler's

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

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

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

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

A nurse is assisting with a community screening for people at high risk for stroke. To which of the following clients would the nurse pay most attention? -A 60-year-old Black man -A 40-year-old White woman -A 62-year-old White woman -A 28-year-old pregnant Black woman

A 60-year-old Black man The 60-year-old Black man has three risk factors: gender, age, and race. Black people have almost twice the incidence of first stroke compared with White people.

A patient had a carotid endarterectomy yesterday and when the nurse arrived in the room to perform an assessment, the patient states, "All of a sudden, I am having trouble moving my right side." What concern should the nurse have about this complaint? -A thrombus formation at the site of the endarterectomy -This is a normal occurrence after an endarterectomy and would not be a concern. -Bleeding from the endarterectomy site -Surgical wound infection

A thrombus formation at the site of the endarterectomy Formation of a thrombus at the site of the endarterectomy is suspected if there is a sudden new onset of neurologic deficits, such as weakness on one side of the body.

The nurse is caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke does the nurse know this client has? -Ischemic -Hemorrhagic -Right-sided -Left-sided

Ischemic Ischemic strokes occur when a thrombus or embolus obstructs an artery carrying blood to the brain; about 80% of strokes are the ischemic variety. The other options are incorrect.

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 -Keeping the client in one position to decrease bleeding -Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess -Maintaining the client in a quiet environment

Keeping the client in one position to decrease bleeding 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 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 -cardiac disease -diabetes insipidus -hypertension

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

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 is caring for a client diagnosed with a hemorrhagic stroke. The nurse recognizes that which intervention is most important? -Elevating the head of the bed to 30 degrees -Monitoring for seizure activity -Administering a stool softener -Maintaining a patent airway

Maintaining a patent airway Maintaining the airway is the most important nursing intervention. Immediate complications of a hemorrhagic stroke include cerebral hypoxia, decreased cerebral blood flow, and extension of the area of injury. Providing adequate oxygenation of blood to the brain minimizes cerebral hypoxia. Brain function depends on delivery of oxygen to the tissues. Administering supplemental oxygen and maintaining hemoglobin and hematocrit at acceptable levels will assist in maintaining tissue oxygenation. All other interventions are appropriate, but the airway takes priority. The head of the bed should be elevated to 30 degrees, monitoring the client because of the risk for seizures, and stool softeners are recommended to prevent constipation and straining, but these are not the most important interventions.

A 76-year-old client is brought to the clinic by his daughter. The daughter states that her father has had two transient ischemic attacks (TIAs) in the past week. The physician orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option does the nurse expect the physician to offer this client to increase blood flow to the brain? -Stent placement -Removal of the carotid artery -Percutaneous transluminal coronary artery angioplasty -Carotid endarterectomy

Carotid endarterectomy If narrowing of the carotid artery by atherosclerotic plaques is the cause of the TIAs, a carotid endarterectomy (surgical removal of atherosclerotic plaque) is a treatment option. A balloon angioplasty, a procedure similar to a percutaneous transluminal coronary artery angioplasty, is performed to dilate the carotid artery and increase blood flow to the brain. Options A, B, and C are not surgical options to increase blood flow through the carotid artery to the brain.

A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings? -Transient ischemic attack (TIA) -Left-sided cerebrovascular accident (CVA) -Right-sided cerebrovascular accident (CVA) -Completed Stroke

Left-sided cerebrovascular accident (CVA) When the infarct is on the left side of the brain, the symptoms are likely to be on the right, and the speech is more likely to be involved. If the MRI reveals an infarct, TIA is no longer the diagnosis. There is not enough information to determine if the stroke is still evolving or is complete.

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

Cerebral aneurysm 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? -Nausea, vomiting, and profuse sweating -Hemiplegia, seizures, and decreased level of consciousness -Difficulty breathing or swallowing -Tachycardia, tachypnea, and hypotension

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.

An emergency department nurse is interviewing a client who is presenting with signs of an ischemic stroke that began 2 hours ago. The client reports a history of a cholecystectomy 6 weeks ago and is taking digoxin, warfarin, and labetalol. What factor poses a threat to the client for thrombolytic therapy? -International normalized ratio greater than 2 -Two hour time period of the stroke -Taking digoxin -Surgery 6 weeks ago

International normalized ratio greater than 2 The client is at risk for further bleeding if the international normalized ratio is greater than 2. Thrombolytic therapy must be initiated within 3 hours in clients with ischemic stroke. The client is not eligible for thrombolytic therapy if she has had surgery within 14 days. Digoxin and labetalol do not prohibit 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 -One hour -Two hours -Six hours

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 client is hospitalized when presenting to the emergency department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to his presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what? -Transient ischemic attack -Cerebral aneurysm -Right-sided stroke -Left-sided stroke

Transient ischemic attack A transient ischemic attack (TIA) is a sudden, brief attack of neurologic impairment caused by a temporary interruption in cerebral blood flow. Symptoms may disappear within 1 hour; some continue for as long as 1 day. When the symptoms terminate, the client resumes his or her presymptomatic state. The symptoms do not describe a left- or right-sided stroke or a cerebral aneurysm.

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

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

Which insult or abnormality can cause an ischemic stroke? -Cocaine use -Arteriovenous malformation -Trauma -Intracerebral aneurysm rupture

Cocaine use Cocaine is a potent vasoconstrictor and may result in a life-threatening reaction, even with the individual's first use of the drug. Arteriovenous malformations, trauma, and intracerebral aneurysm rupture are associated with hemorrhagic stroke.

A client is experiencing dysphagia following a stroke. Which measure may be taken by the nurse to ensure that the client's diet allows for easy swallowing? -Instruct the client to lie on the bed when eating. -Offer liquids frequently and in large quantities. -Help the client sit upright when eating and feed slowly. -Allow optimum physical activity before meals to expedite digestion.

Help the client sit upright when eating and feed slowly. Having the client sit upright, preferably out of bed in a chair, and instructing him or her to tuck the chin toward the chest when swallowing will help prevent aspiration. The client may be started on a thick liquid or puréed diet, because these foods are easier to swallow than thin liquids. The diet may be advanced as the client becomes more proficient at swallowing. If the client cannot resume oral intake, a gastrointestinal feeding tube is placed for ongoing tube feedings and medication administration. The client should be allowed to rest before meals because fatigue may interfere with coordination and following instructions.

Which of the following is the initial diagnostic in suspected stroke? -Noncontrast computed tomography (CT) -CT with contrast -Magnetic resonance imaging (MRI) -Cerebral angiography

Noncontrast computed tomography (CT) An initial head CT scan will determine whether or not the patient is experiencing a hemorrhagic stroke. An ischemic infarction will not be readily visible on initial CT scan if it is performed within the first few hours after symptoms onset; however, evidence of bleeding will almost always be visible.

The nurse is caring for a client with dysphagia. Which intervention would be contraindicated while caring for this client? -Assisting the client with meals -Placing food on the affected side of the mouth -Testing the gag reflex before offering food or fluids -Allowing ample time to eat

Placing food on the affected side of the mouth Interventions for dysphagia include placing food on the unaffected side of the mouth, allowing ample time to eat, assisting the client with meals, and testing the client's gag reflex before offering food or fluids.

Which is indicative of a right hemisphere stroke -Aphasia -Spatial-perceptual deficits -Slow, cautious behavior -Altered intellectual ability

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