Complex

A patient diagnosed with a stroke is ordered to receive warfarin (Coumadin). Later, the nurse learns that the warfarin is contraindicated and the order is canceled. The nurse knows that the best alternative medication to give is which of the following?

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

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

Bleeding

How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tPA)?

Every 15 minutes

global aphasia

Form words that are understandable or comprehend the spoken word Explanation: Global aphasia is a combination of expressive and receptive aphasia and presents tremendous challenge to the nurse to effectively communicate with the patient. The patient who is unable to speak at all is referred to as mute.

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?

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 practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regime, 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:

Hypertension

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?

Lioresal (Baclofen)

Which of the following clinical manifestations would be exhibited by a patient following a hemorrhagic stroke of the right hemisphere?

Neglect of the left side

Eight days following a subarachnoid hemorrhage, a transcranial Doppler ultrasonography detects cerebral vasospasms in a patient experiencing lethargy. The nurse anticipates which of the following therapeutic interventions?

Nimodipine (Nimotop) po Explanation: Medication may be effective in the treatment of vasospasm. Based on one theory, that vasospasm is caused by an increased influx of calcium into the cell, medication therapy may be used to block or antagonize this action and prevent or reverse the action of vasospasm if already present. The most frequently used calcium channel blocker is nimodipine (Nimotop)

The nurse is caring for a patient following an aneurysm coiling procedure. The nurse documents that the patient is experiencing Korsakoff syndrome. Which of the following symptoms characterizes Korsakoff syndrome?

Psychosis, disorientation, delirium, insomnia, and hallucinations

An emergency department nurse is interviewing a client with signs of an ischemic stroke that began 2 hours ago. The client reports that she had a cholecystectomy 6 weeks ago and is taking digoxin, coumadin, and labetelol. This client is not eligible for thrombolytic therapy for which of the following reasons?

She is taking coumadin. Explanation: To be eligible for thrombolytic therapy, the client cannot be taking coumadin. Initiation of thrombolytic therapy must be within 3 hours in clients with ischemic stroke. The client is not eligible for thrombolytic therapy if she has had surgery within 14 days.

What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke?

Spatial-perceptual deficits 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.

When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke?

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

The nurse is caring for a patient with a history of transient ischemic attacks (TIAs) and moderate carotid stenosis who has undergone a carotid endarterectomy. Which of the following postoperative findings would cause the nurse the most concern?

The patient's inability to swallow without difficulty would cause the nurse the most concern. Difficulty in swallowing, hoarseness or other signs of cranial nerve dysfunction must be assessed. The nurse focuses on assessment of the following cranial nerves: facial (VII), vagus (X), spinal accessory (XI), and hypoglossal (XII).

A client is receiving an I.V. 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? Y

The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output.

receptive aphasia

inability to understand spoken or written words

A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the physician in the emergency department. After completing ordered diagnostic tests, the physician indicates to the client what caused the symptoms that brought him to the hospital. What is the origin of the client's symptoms?

mpaired cerebral circulation Explanation: TIAs result from impaired blood circulation in the brain, which can be caused by atherosclerosis and arteriosclerosis, cardiac disease, or diabetes. The symptoms of a TIA are the result of impaired blood circulation in the brain, which may have been caused by cardiac disease. T

During a class on stroke, a junior nursing student asks what the clinical manifestations of stroke are. What would be the instructor's best answer?

"Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation."

An emergency department nurse understands that a 110-lb recent stroke victim will receive at least the minimum dose of recombinant tissue plasminogen activator (t-PA). What minimum dose will the patient receive?

50 mg Correct Explanation: 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.

A client is admitted to the intensive care unit (ICU) with a diagnosis of cerebrovascular accident (CVA). Which assessment by the nurse provides the most significant finding in differentiating between ischemic and hemorrhagic strokes?

A unit of fresh frozen plasma is infusing. Correct Explanation: FFP is usedin the treatment of clotting deficiencies as seen with over dose of anticoagulants and would indicate a hemorrhagic stroke.

A physician orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question?

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 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?

Carotid endarterectomy Explanation: 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.

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?

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

Which disturbance results in loss of half of the visual field?

Homonymous hemianopsia (loss of half of the visual field) may occur from stroke and may be temporary or permanent. Double vision is documented as diplopia. Nystagmus is ocular bobbing and may be seen in multiple sclerosis. Anisocoria is unequal pupils.

A patient is suspected of having had a stroke. Which of the following is the initial diagnostic test for a stroke?

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 ED to determine if the event is ischemic or hemorrhagic (the category of stroke determines treatment). Further diagnostics include a carotid Doppler, ECG, and a transcranial Doppler

A nurse knows that, for a patient with an ischemic stroke, tPA is contraindicated if the blood pressure reading is:

190 mm Hg/120 mm Hg

The nurse recognizes health promotion efforts to decrease the risk for ischemic stroke involve encouraging a healthy lifestyle, including which of the following?

A low-fat, low-cholesterol diet, and increasing exercise

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 medical treatment to include which of the following?

Anticoagulant or antiplatelet therapy can prevent clot formation associated with cardiac dysrhythmias such as atrial fibrillation.

Which of the following terms refer to the inability to perform previously learned purposeful motor acts on a voluntary basis?

Apraxia

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 Explanation: 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.

A client undergoes cerebral angiography for evaluation after an intracranial computed tomography scan revealed a subarachnoid hemorrhage. Afterward, the nurse checks frequently for signs and symptoms of complications associated with this procedure. Which findings indicate spasm or occlusion of a cerebral vessel by a clot?

Hemiplegia, seizures, and decreased level of consciousness (LOC) Correct

Which of the following terms will the nurse use when referring to blindness in the right or left halves of the visual fields of both eyes?

Homonymous hemianopsia

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?

Keeping the client in one position to decrease bleeding Explanation: 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 client who complains of 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 actio

Migraines often coincide with menstrual cycle.

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

A patient is exhibiting classic signs of a hemorrhagic stroke. What complaint from the patient would be an indicator of this type of stroke?

Severe headache

In expressive aphasia,

the patient is unable to form words that are understandable.