Chapter 62 Management of Patients with Cerebrovascular Disorders

The nurse caring for a client with a spinal cord injury notes that the client is exhibiting early signs and symptoms of disuse syndrome. Which of the following is the most appropriate nursing action? Increase the frequency of ROM exercises. Limit the amount of assistance provided with ADLs. Collaborate with the physical therapist and immobilize the client's extremities temporarily. Educate the client about the importance of frequent position changes.

Increase the frequency of ROM exercises. Rationale: To prevent disuse syndrome, ROM exercises must be provided at least four times a day, and care is taken to stretch the Achilles tendon with exercises. The client is repositioned frequently and is maintained in proper body alignment whether in bed or in a wheelchair. The client must be repositioned by caregivers, not just taught about repositioning. It is inappropriate to limit assistance for the sole purpose of preventing disuse syndrome.

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

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

A client who has experienced an initial transient ischemic attack (TIA) states: "I'm glad it wasn't anything serious." Which is the best nursing response to this statement? A) "People who experience a TIA will develop a stroke". B) "I sense that you are happy it was not a stroke". C) "TIA is a warning sign. Let's talk about lowering your risks." D) "TIA symptoms are short-lived and resolve within 24 hours".

C) "TIA is a warning sign. Let's talk about lowering your risks." TIA is a warning sign and can be used to empower clients to make life changes to lower the risks. Sensing the client is happy is a psychotherapeutic response but does not lead to teaching and learning for health promotion. TIAs can lead to a stroke for approximately one third of the clients but is not a definitive result and presents as a frightening statement without empowering change. TIA symptoms are short-lived, but this is a factual statement that does not provide additional information to the client.

Which is a nonmodifiable risk factor for ischemic stroke? Hyperlipidemia Gender Atrial fibrillation Smokeing

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

Which of the following is accurate regarding a hemorrhagic stroke? - Main presenting symptom is an "exploding headache." - One of the main presenting symptoms is numbness or weakness of the face. - It is caused by a large-artery thrombosis. - Functional recovery usually plateaus at 6 months.

Main presenting symptom is an "exploding headache." One of hemorrhagic stroke's main presenting symptom is an "exploding headache." In ischemic stroke, functional recovery usually plateaus at 6 months; it may be caused by a large artery thrombosis and may have a presenting symptoms of numbness or weakness of the face.

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

Noncontrast CT scan 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.

The staff educator is precepting a nurse new to the critical care unit when a client with a T2 spinal cord injury is admitted. The client is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the client closely, what would be the nurse's most appropriate action? - Place the client in the Trendelenburg position. - Prepare an ice bath to lower core body temperature. - Prepare for interventions to increase the client's BP. - Prepare to transfuse packed red blood cells.

Prepare for interventions to increase the client's BP. Manifestations of neurogenic shock include decreased BP and heart rate. Cardiac markers would be expected to rise in cardiogenic shock. Transfusion, repositioning, and ice baths are not indicated interventions.

A nurse on the neurologic unit is providing care for a client who has spinal cord injury at the level of C4. When planning the client's care, what aspect of the client's neurologic and functional status should the nurse consider? Incontinent in bowel movements Requires full assistance for elimination Unable to swallow liquid and solid food Inability to use a wheelchair

Requires full assistance for elimination Rationale: Clients with a lesion at C4 are fully dependent for elimination. The client is dependent for feeding, but is able to swallow. The client will be capable of using an electric wheelchair.

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

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.

Level of consciousness (LOC) can be assessed based on criteria in the Glasgow Coma Scale (GCS). Which of the following indicators are assessed in the GCS? Select all that apply. Verbal response Intelligence Motor response Eye opening Muscle strength

Verbal response, motor response, eye opening LOC can be assessed based on the criteria in the GCS, which include eye opening, verbal response, and motor response. The patient's responses are rated on a scale from 3 to 15. Intelligence and muscle strength are not measured in the GCS.

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? a) Ischemic b) Hemorrhagic c) Right-sided d) Left-sided

a) 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.

Which is a contraindication for the administration of tissue plasminogen activator (t-PA)? a) Ischemic stroke b) Systolic blood pressure less than or equal to 185 mm Hg c) Intracranial hemorrhage d) Age 18 years or older

c) intracranial hemorrhage Intracranial hemorrhage, neoplasm, and aneurysm are contraindications for t-PA. Clinical diagnosis of ischemic stroke, age 18 years or older, and a systolic blood pressure less than or equal to 185 mm Hg are eligibility criteria.

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? a) visual agnosia b) Auditory agnosia c) Limited attention span and forgetfulness d) Lack of deep tendon reflexes

d) 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.

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. Age National Institutes of Health Stroke Scale (NIHSS) score LOC at time of admission Race Gender

Age, NIHSS score, LOC at time admission Rationale: 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.

The nurse is caring for a client with aphasia. Which strategy will the nurse use to facilitate communication with the client? A) Establishing eye contact B) Speaking loudly C) Avoiding the use of hand gestures D) Speaking in complete sentences

Establishing eye contact The following strategies should be used by the nurse to encourage communication with a client with aphasia: face the client and establish eye contact, speak in your usual manner and tone, use short phrases, and pause between phrases to allow the client time to understand what is being said; limit conversation to practical and concrete matters; use gestures, pictures, objects, and writing; and as the client uses and handles an object, say what the object is. It helps to match the words with the object or action. Be consistent in using the same words and gestures each time you give instructions or ask a question, and keep extraneous noises and sounds to a minimum. Too much background noise can distract the client or make it difficult to sort out the message being spoken.

The nurse is caring for a client recovering from an ischemic stroke. What intervention(s) best addresses potential complications after an ischemic stroke? Select all that apply. - Keeping a urinary catheter in place for the full duration of recovery. - Teaching the client to perform deep breathing and coughing exercises. - Limiting intake of insoluble fiber, carbohydrates, and simple sugars. - Encourage the client to stay in bed and assist with turning and repositioning. - Providing frequent small meals rather than three larger meals

Teaching the client to perform deep breathing and coughing exercises; Providing frequent small meals rather than three larger meals Rationale: Because pneumonia is a potential complication of stroke, deep breathing and coughing exercises should be encouraged unless contraindicated. Providing small frequent meals during recovery will decrease the likelihood of aspiration. Dietary restrictions are based on individual client needs, and fiber, carbohydrates, and sugars are not typically restricted. Urinary catheters should be discontinued as soon as possible to prevent the increased risk of catheter associated urinary tract infections (CAUTI). It is also important to get the client out of bed as soon as possible to prevent pressure ulcers and encourage mobility.

A nurse in a rehabilitation facility is coordinating the discharge of a client who is tetraplegic. The client, who is married and has two children in high school, is being discharged to home and will require much assistance. Who would the discharge planner recognize as being the most important member of this client's care team? a) home care nurse b) physical therapist c) chaplain d) spouse

d) spouse The client's spouse and family would need to be involved in the everyday care of the client; without their support, it is unlikely that the client would be able to manage at home.

From which direction should a nurse approach a client who is blind in the right eye? From directly in front of the client From the right side of the client From the left side of the client From directly behind the client`

from the left side of the client The nurse should approach the client from the left side so that the client can be aware of the nurse's approach. Likewise, personal items should be placed on the client's left side so that he can see them easily.

Which of the following is accurate regarding a hemorrhagic stroke? a) Functional recovery usually plateaus at 6 months. b) It is caused by a large-artery thrombosis. c) One of the main presenting symptoms is numbness or weakness of the face. d) Main presenting symptom is an "exploding headache."

d) main presenting symptom is an "exploding headache" One of hemorrhagic stroke's main presenting symptom is an "exploding headache." In ischemic stroke, functional recovery usually plateaus at 6 months; it may be caused by a large artery thrombosis and may have a presenting symptoms of numbness or weakness of the face.

A client recently experienced a stroke with accompanying left-sided paralysis. His family voices concerns about how to best interact with him. They report the client doesn't seem aware of their presence when they approach him on his left side. What advice should the nurse give the family? A) "The client is unaware of his left side. You should approach him on the right side." B) "The client is unaware of his left side. You need to encourage him to interact from this side." C) "This condition is temporary." D) "The client is feeling an emotional loss. He'll eventually start acknowledging you on his left side."

A) "The client is unaware of his left side. You should approach him on the right side." The client is experiencing unilateral neglect and is unaware of his left side. The nurse should advise the family to approach him on his unaffected (right) side. Approaching the client on the affected side would be counterproductive. It's too premature to make the determination whether this condition will be permanent.