Lewis Chapter 58: Stroke

a, d, e Rationale: The patient with a stroke may experience many losses, including sensory, intellectual, communicative, functional, role behavior, emotional, social, and vocational losses. Some patients experience long-term depression, manifesting symptoms such as anxiety, weight loss, fatigue, poor appetite, and sleep disturbances. The time and energy required to perform previously simple tasks can result in anger and frustration. Frustration and depression are common in the first year after a stroke. A stroke is usually a sudden, extremely stressful event for the patient, caregiver, family, and significant others. The family is often affected emotionally, socially, and financially as their roles and responsibilities change. Reactions vary considerably but may involve fear, apprehension, denial of the severity of stroke, depression, anger, and sorrow.

Common psychosocial reactions of the stroke patient to the stroke include (select all that apply) a. depression. b. disassociation. c. intellectualization. d. sleep disturbances. e. denial of severity of stroke.

A. Maintenance of patient's airway. Maintenance of a patent airway is the priority in the acute care of a patient with a hemorrhagic stroke. It supersedes the importance of fluid and electrolyte imbalance and positioning. tPA is contraindicated in hemorrhagic stroke.

Computed tomography (CT) of a 68-year-old male patient's head reveals that he has experienced a hemorrhagic stroke. What is the priority nursing intervention in the emergency department? A. Maintenance of patient's airway. B. Positioning to promote cerebral perfusion. C. Control of fluid and electrolyte imbalances. D. Administration of tissue plasminogen activator (tPA)

b Rationale: During initial evaluation, the most important point in the patient's history is the time since onset of stroke symptoms. If the stroke is ischemic, recombinant tissue plasminogen activator (tPA) must be administered within 3 to 4.5 hours of the onset of clinical signs of ischemic stroke; tPA reestablishes blood flow through a blocked artery and prevents brain cell death in patients with acute onset of ischemic stroke.

For a patient who is suspected of having a stroke, one of the most important pieces of information that the nurse can obtain is a. time of the patient's last meal. b. time at which stroke symptoms first appeared. c. patient's hypertension history and management. d. family history of stroke and other cardiovascular diseases.

d Rationale: A hemorrhagic stroke usually causes a sudden onset of symptoms, which include neurologic deficits, headache, nausea, vomiting, decreased level of consciousness, and hypertension. Ischemic stroke symptoms may progress in the first 72 hours as infarction and cerebral edema increase.

Information provided by the patient that would help differentiate a hemorrhagic stroke from a thrombotic stroke includes a. sensory disturbance. b. a history of hypertension. c. presence of motor weakness. d. sudden onset of severe headache.

d Rationale: Nonmodifiable risk factors for stroke include age (older than 65 years), male gender, ethnicity or race (incidence is highest in African Americans; next highest in Hispanics, Native Americans/Alaska Natives, and Asian Americans; and next highest in white people), and family history of stroke or personal history of a transient ischemic attack or stroke. Modifiable risk factors for stroke include hypertension (most important), heart disease (especially atrial fibrillation), smoking, excessive alcohol consumption (causes hypertension), abdominal obesity, sleep apnea, metabolic syndrome, lack of physical exercise, poor diet (high in saturated fat and low in fruits and vegetables), and drug abuse (especially cocaine). Other risk factors for stroke include a diagnosis of diabetes mellitus, increased serum levels of cholesterol, birth control pills (high levels of progestin and estrogen), history of migraine headaches, inflammatory conditions, hyperhomocystinemia, and sickle cell disease.

Of the following patients, the nurse recognizes that the one with the highest risk for a stroke is a(n) a. obese 45-year-old Native American. b. 35-year-old Asian American woman who smokes. c. 32-year-old white woman taking oral contraceptives. d. 65-year-old African American man with hypertension.

A. giving the patient 8 ounces of ice water to swallow. The majority of patients after a stroke have dysphagia. The gag reflex and swallowing ability (cranial nerves IX and X) should be assessed before the first oral feeding. To assess swallowing ability, the nurse should elevate the head of the bed to an upright position (unless contraindicated) and give the patient a very small amount (not 8 ounces) of crushed ice or ice water to swallow. The patient should remain in a high Fowler's position, preferably in a chair with the head flexed forward, for the feeding and for 30 minutes following.

The nurse observes a student nurse assigned to initiate oral feedings for a 68-year-old woman with an ischemic stroke. The nurse should intervene if she observes the student nurse: A. giving the patient 8 ounces of ice water to swallow. B. telling the patient to perform a chin tuck before swallowing. C. assisting the patient to sit in a chair before feeding the patient. D. assessing cranial nerves IX and X before the patient attempts to eat.

D. Use simple, short sentences accompanied by visual cues to enhance comprehension. When communicating with a patient with aphasia, the nurse should present one thought or idea at a time. Ask questions that can be answered with a "yes," "no," or simple word. Use visual cues and allow time for the individual to comprehend and respond to conversation.

Which intervention is most appropriate when communicating with a patient suffering from aphasia following a stroke? A. Present several thoughts at once so that the patient can connect the ideas. B. Ask open-ended questions to provide the patient the opportunity to speak. C. Finish the patient's sentences to minimize frustration associated with slow speech. D. Use simple, short sentences accompanied by visual cues to enhance comprehension.

A. Hypertension Hypertension is the single most important modifiable risk factor, but it is still often undetected and inadequately treated. The public is often more aware of hyperlipidemia and oral contraceptive use as risk factors for stroke. Alcohol is also a modifiable risk factor.

Which modifiable risk factors for stroke would be most important for the nurse to include when planning a community education program? A. Hypertension B. Hyerlipidemia C. Alcohol consumption D. Oral contraceptive use

term used to describe a stroke; communicates the urgency of recognizing the clinical manifestations of a stroke and treating a medical emergency

brain attack

term used to describe a stroke

cerebrovascular accident (CVA)

a disturbance in the muscular control of speech, resulting from interference in the control and execution over the muscles of speech, usually caused by damage to a central or peripheral motor nerve

dysarthria

difficulty related to the comprehension or use of language

dysphasia

a stroke that results from bleeding into the brain tissue itself (intracerebral or intraparenchymal hemorrhage) or into the subarachnoid space or ventricles (subarachnoid hemorrhage or intraventricular hemorrhage)

hemorrhagic stroke

a type of hemorrhagic stroke in which bleeding within the brain caused by a rupture of a blood vessel occurs; often caused by hypertension and is associated with increased intracranial pressure

intracerebral hemorrhage

stroke that results from inadequate blood flow to the brain caused by partial or complete occlusion of an artery

ischemic stroke

a stroke resulting from occlusion of a small penetrating artery with development of a cavity in the place of the infarcted brain tissue

lacunar stroke

death of brain cells that occurs when there is ischemia (inadequate blood flow) to a part of the brain or hemorrhage into the brain

stroke

a stroke resulting from intracranial bleeding into the cerebrospinal fluid-filled space between the arachnoid and pia mater membranes on the surface of the brain

subarachnoid hemorrhage

D. Arrange for several servings per day of cooked fruits and vegetables. Patients after a stroke frequently have constipation. Dietary management includes the following: fluid intake of 2500 to 3000 mL daily, prune juice (120 mL) or stewed prunes daily, cooked fruit three times daily, cooked vegetables three times daily, and whole-grain cereal or bread three to five times daily. Patients with urinary incontinence should be assisted to the bathroom every 2 hours when appropriate. Suppositories may be ordered for short-term management if the patient does not respond to increased fluid and fiber. Incontinence briefs are indicated as a short-term intervention for urinary incontinence.

A 74-year-old man who has right-sided extremity paralysis related to a thrombotic stroke develops constipation. Which action should the nurse take first? A. Assist the patient to the bathroom every 2 hours. B. Provide incontinence briefs to wear during the day. C. Administer a bisocodyl (Dulcolax) rectal suppository every day. D. Arrange for several servings per day of cooked fruits and vegetables.

B. Alternate the patient's positioning between supine and side-lying. A position change schedule should be established for stroke patients. An example is side-back-side, with a maximum duration of 2 hours for any position. The patient should be positioned on the weak or paralyzed side for only 30 minutes. Pillows may be used to facilitate positioning. Areas of skin breakdown should never be massaged.

A female patient has left-sided hemiplegia following an ischemic stroke that she experienced 4 days earlier. How should the nurse best promote the health of the patient's integumentary system? A. Position the patient on her weak side the majority of the time. B. Alternate the patient's positioning between supine and side-lying. C. Avoid the use of pillows in order to promote independence in positioning. D. Establish a schedule for the message of areas where skin breakdown emerges.

c Rationale: In a carotid endarterectomy, the atheromatous lesion is removed from the carotid artery to improve blood flow.

A patient experiencing TIAs is scheduled for a carotid endarterectomy. The nurse explains that this procedure is done to a. decrease cerebral edema. b. reduce the brain damage that occurs during a stroke in evolution. c. prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow. d. provide a circulatory bypass around thrombotic plaques obstructing cranial circulation.

c Rationale: If the middle cerebral artery is involved in a stroke, the expected clinical manifestations include aphasia, motor and sensory deficit, and hemianopsia on the dominant side and include neglect, motor and sensory deficit, and hemianopsia on the nondominant side.

A patient with right-sided hemiplegia and aphasia resulting from a stroke most likely has involvement of the a. brainstem. b. vertebral artery. c. left middle cerebral artery. d. right middle cerebral artery.

c Rationale: In the acute stage of stroke, the primary urinary problem is poor bladder control and incontinence. Nurses should promote normal bladder function and avoid the use of indwelling catheters. A bladder retraining program consists of (1) adequate fluid intake, with most fluids administered between 7:00 am and 7:00 pm; (2) scheduled toileting every 2 hours with the use of a bedpan, commode, or bathroom; and (3) noting signs of restlessness, which may indicate the need for urination. Intermittent catheterization may be used for urinary retention (not urinary incontinence). During the rehabilitation phase after a stroke, nursing interventions focused on urinary continence include (1) assessment for bladder distention by palpation; (2) offering the bedpan, urinal, commode, or toilet every 2 hours during waking hours and every 3 to 4 hours at night; (3) using a direct command to help the patient focus on the need to urinate; (4) assistance with clothing and mobility; (5) scheduling most fluid intake between 7:00 am and 7:00 pm; and (6) encouraging the usual position for urinating (i.e., standing for men and sitting for women).

Bladder training in a male patient who has urinary incontinence after a stroke includes a. limiting fluid intake. b. keeping a urinal in place at all times. c. assisting the patient to stand to void. d. catheterizing the patient every 4 hours.

D. 65-year-old African American man with hypertension. Nonmodifiable risk factors for stroke include age (older than 65 years), male gender, ethnicity or race (incidence is highest in African Americans; next highest in Hispanics, Native Americans/Alaska Natives, and Asian Americans; and next highest in white people), and family history of stroke or personal history of a transient ischemic attack or stroke. Modifiable risk factors for stroke include hypertension (most important), heart disease (especially atrial fibrillation), smoking, excessive alcohol consumption (causes hypertension), abdominal obesity, sleep apnea, metabolic syndrome, lack of physical exercise, poor diet (high in saturated fat and low in fruits and vegetables), and drug abuse (especially cocaine). Other risk factors for stroke include a diagnosis of diabetes mellitus, increased serum levels of cholesterol, birth control pills (high levels of progestin and estrogen), history of migraine headaches, inflammatory conditions, hyperhomocystinemia, and sickle cell disease.

Of the following patients, the nurse recognizes that the one with the highest risk for stroke is a(n): A. obese 45-year old Native American. B. 35-year-old Asian American woman who smokes. C. 32-year-old white woman taking oral contraceptives. D. 65-year-old African American man with hypertension.

c Rationale: The extent of the stroke depends on the rapidity of onset, size of the lesion, and presence of collateral circulation.

The factor related to cerebral blood flow that most often determines the extent of cerebral damage from a stroke is the a. amount of cardiac output. b. oxygen content of the blood. c. degree of collateral circulation. d. level of carbon dioxide in the blood.

D. Subarachnoid hemorrhage Headache is common in a patient who has a subarachnoid hemorrhage or an intracerebral hemorrhage. A TIA is a transient loss of neurologic function usually without a headache. A headache may occur with an ischemic embolic stroke, but severe neurologic deficits are the initial symptoms. The ischemic thrombotic stroke manifestations progress in the first 72 hours as infarction and cerebral edema increase.

The female patient has been brought to the ED with a sudden onset of a severe headache that is different from any other headache she has had previously. When considering the possibility of a stroke, which type of stroke should the nurse know is most likely occurring? A. TIA B. Embolic stroke C. Thrombotic stroke D. Subarachnoid hemorrhage

c Rationale: Angiography provides visualization of cerebral blood vessels and can help estimate perfusion and detect filling defects in the cerebral arteries.

The nurse explains to the patient with a stroke who is scheduled for angiography that this test is used to determine the a. presence of increased ICP. b. site and size of the infarction. c. patency of the cerebral blood vessels. d. presence of blood in the cerebrospinal fluid.

D. A 72-year-old male who has hypertension and diabetes mellitus and smokes tobacco. Stroke risk increases after 65 years of age. Strokes are more common in men. Hypertension is the single most important modifiable risk factor for stroke. Diabetes mellitus is a significant stroke risk factor; and smoking nearly doubles the risk of a stroke. Other risk factors include drug abuse (especially cocaine), high-dose oral contraception use, migraine headaches, and untreated heart disease such as atrial fibrillation.

The nurse in a primary care provider's office is assessing several patients today. Which patient is most at risk for a stroke? A. A 92-year-old female who takes warfarin (Coumadin) for atrial fibrillation. B. A 28-year-old male who uses marijuana after chemotherapy to control nausea. C. A 42-year-old female who takes oral contraceptives and has migraine headaches. D. A 72-year-old male who has hypertension and diabetes mellitus and smokes tobacco.

A. Clopidogrel (Plavix) C. Dipyridamole (Persantine) D. Enteric-coated aspirin (Ecotrin) Aspirin is the most frequently used antiplatelet agent. Other drugs to prevent clot formation include clopidogrel (Plavix), dipyridamole (Persantine), ticlopidine (Ticlid), combined dipyridamole and aspirin (Aggrenox), and anticoagulant drugs, such as oral warfarin (Coumadin). Tissue plasminogen activator is a fibrinolytic medication used to treat ischemic stroke not prevent TIAs or strokes.

The nurse is discharging a patient admitted with a transient ischemic attack (TIA). For which medications might the nurse expect to provide discharge instructions (select all that apply)? A. Clopidogrel (Plavix) B. Enoxaparin (Lovenox) C. Dipyridamole (Persantine) D. Enteric-coated aspirin (Ecotrin) E. Tissue plasminogen activator (tPA)

C. Rehabilitation potential of the patient Although a patient's neurologic deficit might initially be severe after a stroke, the ability of the patient to recover is most likely to positively impact the family's coping with the situation. Providing explanations and emotional support beginning in the acute phase through the rehabilitation phase will facilitate coping. Emphasizing successes will offer the most realistic hope for the patient's rehabilitation and helps maintain hope for the patient's future abilities.

The nurse is planning psychosocial support for the patient and family of the patient who suffered a stroke. What factor will most likely have the greatest impact on positive family coping with the situation? A. Specific patient neurologic deficits B. The patient's ability to communicate C. Rehabilitation potential of the patient D. Presence of complications of a stroke

D. "Call 911 immediately if a person develops slurred speech or difficulty speaking." Medical assistance should be obtained immediately for someone with signs and symptoms of a stroke such as sudden numbness; weakness; paralysis of the face, arm, or leg (especially on one side of the body); sudden confusion; trouble speaking or understanding; slurred speech; sudden trouble seeing in one or both eyes; sudden trouble walking; dizziness; loss of balance or coordination; or a sudden, severe headache with no known cause. A person with signs and symptoms of a transient ischemic attack should seek medical attention immediately because it is unknown if the symptoms will resolve or persist and progress to a stroke. Onset of signs and symptoms of a stroke vary depending on the type. Onset of an ischemic thrombotic stroke usually occurs at rest. Onset of an ischemic embolic stroke is not related to rest or activity, and onset of a hemorrhagic stroke usually occurs with activity.

The nurse is teaching a senior citizen's group about signs and symptoms of a stroke. Which statement by the nurse would provide accurate information? A. "Take the person to the hospital if a headache lasts for more than 24 hours." B. "Stroke symptoms usually start when the person is awake and physically active." C. "A person with a transient ischemic attack has mild symptoms that will go away." D. "Call 911 immediately if a person develops slurred speech or difficulty speaking."

B. Impaired speech Clinical manifestations of left-sided brain damage include right hemiplegia, impaired speech/language, impaired right/left discrimination, and slow and cautious performance. Impulsivity, left-sided neglect, and short attention span are all manifestations of right-sided brain damage.

The nurse would expect to find what clinical manifestation in a patient admitted with a left-sided stroke? A. Impulsivity B. Impaired speech C. Left-side neglect D. Short attention span

A. Safety measures A patient with a right-sided stroke has spatial-perceptual deficits, tends to minimize problems, has a short attention span, is impulsive, and may have impaired judgment. Safety is the biggest concern for this patient. Hemiplegia occurs on the left side of this patient's body. The patient with a left-sided stroke has hemiplegia on the right, is more likely to have communication problems, and needs mobility assistance on the right side with food placed on the left side if the patient needs to be fed after a swallow evaluation has taken place.

The patient with diabetes mellitus has had a right-sided stroke. Which nursing intervention should the nurse plan to provide for this patient related to expected manifestations of this stroke? A. Safety measures B. Patience with communication C. Mobility assistance on the right side D. Place food in the left side of patient's mouth

B. Insert two or three large-bore IV catheters before administering the medication. Before giving alteplase, the nurse should start two or three large bore IVs. Bleeding is a major complication with fibrinolytic therapy, and venipunctures should not be attempted after alteplase is administered. Altepase is administered IV with an initial bolus dose followed by an infusion of the remaining medication within the next 60 minutes. Gingival bleeding is a minor complication and may be controlled with pressure or ice packs. Control of blood pressure is critical prior to altepase administration and for the following 24 hours. Before administering altepase, a systolic pressure above 180 mm Hg or diastolic pressure above 110 mm Hg requires aggressive blood pressure treatment to reduce the risk of cerebral hemorrhage.

The physician orders alteplase (Activase) for a 58-year-old man diagnosed with an acute ischemic stroke. Which nursing action is most appropriate? A. Administer the medication by an IV route at 15 mL/hr for 24 hours. B. Insert two or three large-bore IV catheters before administering the medication. C. If gingival bleeding occurs, discontinue the medication and notify the physician. D. Reduce the medication infusion rate for a systolic blood pressure above 180 mm Hg.

C. Slow and possibly fearful performance of tasks. Patients with a left-sided stroke (right hemiplegia) commonly are slower in organization and performance of tasks and may have a fearful, anxious response to a stroke. Overconfidence, spatial disorientation, and impulsivity are more commonly associated with a right-sided stroke.

Which sensory-perceptual deficit is associated with left-sided stroke (right hemiplegia)? A. Overestimation of physical abilities. B. Difficulty judging position and distance. C. Slow and possibly fearful performance of tasks. D. Impulsivity and impatience at performing tasks.

congenital or acquired weakness of the arterial wall resulting in dilation and ballooning of the vessel

aneurysms

an abnormal neurologic condition in which language function is disordered or absent because of an injury to certain areas of the cerebral cortex

aphasia

a stroke that occurs when an embolus lodges in and occludes a cerebral artery, resulting in infarction and edema of the area supplied by the involved vessel

embolic stroke

a stroke resulting from thrombosis or narrowing of the blood vessel

thrombotic stroke

a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, but without acute infarction of the brain. Clinical symptoms typically last less than 1 hour

transient ischemic attack (TIA)