Chapter 67, Management of Patients with Cerebrovascular Disorders

penumbra region

area of low cerebral blood flow

Hemianopsia

blindness of half of the field of vision in one or both eyes

aphasia

inability to express oneself or to understand language

expressive aphasia

inability to express oneself; often associated with damage to the left frontal lobe area

agnosia

loss of ability to recognize objects through a particular sensory system; may be visual, auditory, or tactile

infarction

tissue necrosis in an area deprived of blood supply

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? 1. Apply warm or cool cloths to the forehead or back of the neck. 2. Maintain hydration by drinking eight glasses of fluid a day. 3. Use pressure-relieving pads or a similar type of mattress. 4. Perform the Heimlich maneuver.

1. Apply warm or cool cloths to the forehead or back of the neck. Warmth promotes vasodilation; cool stimuli reduce blood flow.

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? 1. Help the client sit upright when eating and feed slowly. 2. Instruct the client to lie on the bed when eating. 3. Allow optimum physical activity before meals to expedite digestion. 4. Offer liquids frequently and in large quantities.

1. 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.

The nurse is caring for a client diagnosed with a hemorrhagic stroke. The nurse recognizes that which intervention is most important? 1. Monitoring for seizure activity 2. Maintaining a patent airway 3. Elevating the head of the bed to 30 degrees 4. Administering a stool softener

2. 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.

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? 1. Two hours 2. Three hours 3. One hour 4. Six hours

2. 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 physician orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? 1. Phenytoin (Dilantin) 2. Methyldopa (Aldomet) 3. Heparin sodium 4. Dexamethasone (Decadron)

3. 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 physician may use dexamethasone to decrease cerebral edema and pressure; methyldopa, to reduce blood pressure; and phenytoin, to prevent seizures.

A client has a 12-year history of migraine headaches and is frustrated over how these headaches impact lifestyle. The nurse discusses the potential triggers of the client's migraines. Which is not a potential trigger to migraines? 1. seasonal changes 2. specific food chemicals 3. medications 4. reproductive hormone fluctuations

3. medications Researchers believe the contributing cofactors for the cause of migraines are from changes in serotonin receptors that promote dilation of cerebral blood vessels and pain intensification from neurochemicals released from the trigeminal nerve. It has been suggested that fluctuations in reproductive hormones, chemicals in certain foods, and medications can trigger migraines.

Which of the following antiseizure medication has been found to be effective for post-stroke pain? 1. Phenytoin (Dilantin) 2. Carbamazepine (Tegretol) 3. Topiramate (Topamax) 4. Lamotrigine (Lamictal)

4. Lamotrigine (Lamictal) The antiseizure medication lamotrigine (Lamictal) has been found to be effective for post-stroke pain.

A client is experiencing severe pain related to increased ICP. Which analgesic would be ordered for this client to help alleviate pain? 1. hydrocodone 2. morphine 3. fentanyl 4. codeine

4. codeine Avoid administering opioid analgesics, except codeine. Opioids interfere with accurate assessment of neurologic function because they constrict the pupils and depress LOC.

aneurysm

a weakening or bulge in an arterial wall

A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to perform which action? 1. Form words that are understandable or comprehend spoken words 2. Comprehend spoken words 3. Speak at all 4. Form words that are understandable

1. 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.

Which terms refers to blindness in the right or left half of the visual field in both eyes? 1. Scotoma 2. Nystagmus 3. Homonymous hemianopsia 4. Diplopia

3. Homonymous hemianopsia Homonymous hemianopsia occurs with occipital lobe tumors. Scotoma refers to a defect in vision in a specific area in one or both eyes. Diplopia refers to double vision or the awareness of two images of the same object occurring in one or both eyes. Nystagmus refers to rhythmic, involuntary movements or oscillations of the eyes.

A nurse is teaching a community class that those experiencing symptoms of ischemic stroke need to enter the medical system early. The primary reason for this is which of the following? 1. Intracranial pressure is increased by a space-occupying bleed. 2. A ruptured intracranial aneurysm must quickly be repaired. 3. Thrombolytic therapy has a time window of only 3 hours. 4. A ruptured arteriovenous malformation will cause deficits until it is stopped.

3. Thrombolytic therapy has a time window of only 3 hours. Currently approved thrombolytic therapy for ischemic strokes has a treatment window of only 3 hours after the onset of symptoms. Urgency is needed on the part of the public for rapid entry into the medical system. The other three choices are related to hemorrhagic strokes.

Apraxia

inability to perform previously learned purposeful motor acts on a voluntary basis

receptive aphasia

inability to understand what someone else is saying; often associated with damage to the temporal lobe area

A client with a history of atrial fibrillation has experienced a TIA. In an effort to reduce the risk of cerebrovascular accident (CVA), the nurse anticipates the priority medical treatment to include which of the following? 1. Anticoagulant therapy 2. Monthly prothrombin levels 3. Cholesterol-lowering drugs 4. Carotid endarterectomy

1. Anticoagulant therapy Anticoagulant or antiplatelet therapy can prevent clot formation associated with cardiac dysrhythmias such as atrial fibrillation. Cholesterol-lowering drugs can be ordered if indicated to manage atherosclerosis. Prothrombin and international normalized ratio (INR) levels may be ordered to monitor therapeutic effects of anticoagulant therapy. Carotid endarterectomy would be anticipated only when the carotids have narrowing from plaque.

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? 1. Ischemic 2. Hemorrhagic 3. Right-sided 4. Left-sided

1. 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.

The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient? 1. Semi-Fowler's 2. Prone 3. High-Fowler's 4. Supine

1. 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 providing diet-related advice to a male patient following a cerebrovascular accident (CVA). The patient wants to minimize the volume of food and yet meet all nutritional elements. Which of the following suggestions should the nurse give to the patient about controlling the volume of food intake? 1. Provide a high-fat diet. 2. Provide thickened commercial beverages and fortified cooked cereals. 3. Include dry or crisp foods and chewy meats. 4. Always serve hot or tepid foods.

2. Provide thickened commercial beverages and fortified cooked cereals. Patients with CVA or other cerebrovascular disorders should lose weight and therefore should minimize their volume of food consumption. To ensure this, the nurse may provide thickened commercial beverages, fortified cooked cereals, or scrambled eggs. Patients should avoid eating high-fat foods, and serving foods hot or tepid will not minimize the volume consumed by the patient. Foods such as peanut butter, bread, tart foods, dry or crisp foods, and chewy meats should also be avoided because they cause choking.

How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tPA)? 1. Every 30 minutes 2. Every hour 3. Every 45 minutes 4. Every 15 minutes

4. 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 patient is brought to the emergency department with a possible stroke. What initial diagnostic test for a stroke, usually performed in the emergency department, would the nurse prepare the patient for? 1. Carotid ultrasound study 2. Transcranial Doppler flow study 3. 12-lead electrocardiogram 4. Noncontrast computed tomogram

4. Noncontrast computed tomogram 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 patient presents to the emergency department (ED) to determine if the event is ischemic or hemorrhagic (the category of stroke determines treatment).

dysphagia

difficulty swallowing

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? 1. A 60-year-old African-American man 2. A 28-year-old pregnant African-American woman 3. A 62-year-old Caucasian woman 4. A 40-year-old Caucasian woman

1. A 60-year-old African-American man The 60-year-old African-American man has three risk factors: gender, age, and race. African Americans have almost twice the incidence of first stroke compared with Caucasians.

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? 1. severe exploding headache 2. left-sided weakness 3. slurred speech 4. difficulty finding appropriate words

1. 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.

Which of the following is accurate regarding a hemorrhagic stroke? 1. It is caused by a large-artery thrombosis. 2. Main presenting symptom is an "exploding headache." 3. One of the main presenting symptoms is numbness or weakness of the face. 4. Functional recovery usually plateaus at 6 months.

2. 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 nurse is teaching a community class that those experiencing symptoms of ischemic stroke need to enter the medical system early. The primary reason for this is which of the following? 1. A ruptured arteriovenous malformation will cause deficits until it is stopped. 2. Thrombolytic therapy has a time window of only 3 hours. 3. A ruptured intracranial aneurysm must quickly be repaired. 4. Intracranial pressure is increased by a space-occupying bleed.

2. Thrombolytic therapy has a time window of only 3 hours. Currently approved thrombolytic therapy for ischemic strokes has a treatment window of only 3 hours after the onset of symptoms. Urgency is needed on the part of the public for rapid entry into the medical system. The other three choices are related to hemorrhagic strokes.

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? 1. TIA 2. bruit 3. atherosclerotic plaque 4. diplopia

2. 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 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? 1. Cardiogenic emboli 2. Large artery thrombosis 3. Cerebral aneurysm 4. Small artery thrombosis

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

During assessment of cognitive impairment, post-stroke, the nurse documents that the patient was experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe? 1. Occipital 2. Parietal 3. Frontal 4. Temporal

3. Frontal Frontal lobe damage results in impaired learning capacity, memory, and other higher cortical intellectual functions.

A client is receiving an IV infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant? 1. Decreased level of consciousness (LOC) 2. Elevated blood pressure 3. Increased urine output 4. Decreased heart rate

3. 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 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? 1. Completed Stroke 2. Right-sided cerebrovascular accident (CVA) 3. Left-sided cerebrovascular accident (CVA) 4. Transient ischemic attack (TIA)

3. 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.

What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke? 1. Slow, cautious behavior 2. Aphasia 3. Altered intellectual ability 4. Left visual field deficit

4. 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.

dysarthria

defects of articulation due to neurologic causes

hemiplegia

paralysis of one side of the body, or part of it, due to an injury in the motor area of the brain

hemiparesis

weakness of one side of the body, or part of it, due to an injury in the motor area of the brain