MS2- Exam 3- Stroke

Which condition presents with a sudden onset of a headache, vomiting, and decreased level of consciousness? A. Embolic stroke B. Brain infarction C. Cerebral edema D. Hemorrhagic stroke

ANS: D Rationale: Clinical manifestations of hemorrhagic stroke include a sudden onset of symptoms like headache and vomiting with a change in mental status. Embolic stroke and brain infarction symptoms are related to a change in mental status and functional weakness or disability. Cerebral edema has a gradual onset as the brain swells.

Which clinical manifestation is associated with left-hemispheric stroke? A. Impulsivity B. Impaired speech C. Left-side neglect D. Short attention span

ANS: B Rationale: Clinical manifestations of left-hemispheric stroke 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.

Which ethnic group has the highest incidence of stroke? A. Asians B. Mexicans C. Caucasians D. Blacks

ANS: D Rationale: Blacks have twice the incidence of stroke and a higher death rate from stroke compared to any other ethnic group. This may be related in part to a higher incidence of hypertension, obesity, and diabetes. Caucasians, Mexicans, and Asians have a lower risk of stroke than do blacks.

At which rate must blood flow in the brain be maintained for normal functioning? A. 200 to 400 mL/min B. 400 to 600 mL/min C. 650 to 750 mL/min D. 750 to 1000 mL/min

ANS: D Rationale: Blood flow must be maintained at 750 to 1000 mL/min (55 mL/100 g of brain tissue), or 20% of the cardiac output, for optimal brain functioning. Anything below that level, neurologic metabolism is altered.

Which type of stroke is a patient at risk for if atrial fibrillation is untreated? A. Embolic stroke B. Thrombotic stroke C. Intracerebral hemorrhage D. Subarachnoid hemorrhge

ANS: A Heart conditions such as atrial fibrillation and infective endocarditis can cause embolic stroke. A thrombotic stroke has clinical manifestations of decreased level of consciousness in the first 24 hours. Intracerebral hemorrhage has clinical manifestations such as decreased level of consciousness and hypertension. Clinical manifestations such as stiff neck and cranial nerve deficits indicate a subarachnoid hemorrhage.

Which clinical manifestation is associated with a stroke on the right side of the brain? A. Impulsiveness B. Impaired speech C. Slow performance D. Paralyzed right side

ANS: A Rationale: A patient who sustains a stroke on the right side of the brain shows impulsiveness. Impaired speech, slow performance, and a paralyzed right side occur when a patient has had a stroke on the left side of the brain.

Which medical condition places a patient at a higher risk for an embolic stroke? A. Atrial fibrillation B. Atherosclerosis C. Cancer of the brain D. Anticoagulant therapy

ANS: A Rationale: Atrial fibrillation can cause a significant number of embolic strokes. Anticoagulant therapy can cause hemorrhage strokes. Cancer of the brain is related to a mass in the cranium, not the blood vessels. Atherosclerosis causes narrowing of the blood vessels and reduces cranial blood flow and is a risk factor for thrombotic stroke.

A female patient who had a stroke 24 hours ago has expressive aphasia. What is an appropriate nursing intervention to help the patient communicate? A. Ask questions that the patient can answer with "yes" or "no." B. Develop a list of words that the patient can read and practice reciting. C. Have the patient practice her facial and tongue exercises with a mirror. D. Prevent embarrassing the patient by answering for her if she does not respond.

ANS: A Rationale: Communication will be facilitated and less frustrating to the patient when questions that require a "yes" or "no" response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to respond.

Which issue would the nurse prioritize when planning care for a patient in the acute phase of an ischemic stroke? A. Impaired breathing B. Dysphagia C. Impaired verbal communication D. Muscle atrophy of paralyzed side

ANS: A Rationale: During the acute phase after a stroke, management of the respiratory system is a nursing priority. Stroke patients are vulnerable to respiratory problems. Dysphagia is also a concern, but management of the respiratory system is a higher priority. Impaired verbal communication and muscle atrophy of the paralyzed side are more of a concern in the rehabilitation phase.

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

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

Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness. Which patient problem do they determine has the highest priority for the patient? A. Risk for aspiration B. Impaired skin integrity C. Impaired physical mobility D. Disturbed sensory perception

ANS: A Rationale: Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other diagnoses are also appropriate, but interventions to prevent aspiration are the priority at this time.

Which information will a transcranial Doppler (TCD) ultrasonography provide? A. It measures the velocity of blood flow. B. It identifies red blood cells. C. It visualizes blood vessels. D. It measures oxygenation.

ANS: A Rationale: TCD is used to measure the velocity of blood flow in the cerebral arteries. A lumbar puncture identifies red blood cells in the cerebrospinal fluid. A CT scan visualizes the cerebral blood vessels. The LICOX system is used to measure brain oxygenation and temperature.

Which lobe of the brain is affected if a patient has Broca's aphasia? A. Frontal lobe B. Parietal lobe C. Occipital lobe D. Temporal lobe

ANS: A Rationale: The frontal lobe of the brain is related to reasoning, planning, parts of speech, movement, emotions, and problem solving. Broca's aphasia causes the patient to speak in short fragments and is caused by damage to the frontal lobe of the brain. The parietal lobe, occipital lobe, and temporary lobes of the brain are not associated with Broca's aphasia.

A patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will the nurse include in the plan of care? A. Apply intermittent pneumatic compression stockings. B. Assist to dangle on edge of bed and assess for dizziness. C. Encourage patient to cough and deep breathe every 4 hours. D. Insert an oropharyngeal airway to prevent airway obstruction.

ANS: A Rationale: The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thromboembolism. Activities, such as coughing and sitting up, that might increase intracranial pressure or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate.

Which artery would be obstructed if a patient sustained a stroke and is experiencing cranial nerve deficits? A. Vertebral artery B. Middle cerebral artery C. Anterior cerebral artery D. Posterior cerebral artery

ANS: A Rationale: The vertebral artery supplies blood to the posterior part of the circle of Willis. Any impairment in the vertebral artery leads to cranial nerve deficits. The middle cerebral artery supplies blood to the cerebrum and is not associated with cranial nerve deficits. The anterior cerebral artery supplies blood to the middle portions of the frontal lobes and superior medial parietal lobes and is not associated with cranial nerve deficits. The posterior cerebral artery supplies blood to the occipital lobe and is not a cause of cranial nerve deficits.

After receiving change-of-shift report on the following four patients, which patient should the nurse see first? A. A 60-yr-old patient with right-sided weakness who has an infusion of tPA prescribed B. A 50-yr-old patient who has atrial fibrillation and a new order for warfarin (Coumadin) C. A 30-yr-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine scheduled D. A 40-yr-old patient who had a transient ischemic attack yesterday and has a dose of aspirin due

ANS: A Rationale: tPA needs to be infused within the first few hours after stroke symptoms start to be effective in minimizing brain injury. The other medications should also be given as quickly as possible, but timing of the medications is not as critical.

Which diagnostic tests are a priority for a patient who had a stroke and needs a cardiac assessment? Select all that apply. A. Chest x-ray B. Cardiac markers C. Electrocardiogram D. CT E. Complete blood count

ANS: A, B, C Rationale: A chest x-ray can determine whether cardiac enlargement is present. Serum cardiac markers (or cardiac enzymes) are useful in determining whether cardiac function has been disrupted. Electrocardiograms are used to record the electrical activity of the heart and to detect abnormalities in conduction. CT is used to diagnose the initial stroke and to learn the extent of involvement. CT would not reveal a patient's cardiac status. A complete blood count will not give information regarding the cardiac status of a patient.

A nurse is planning a community-based stroke awareness/prevention health fair. Which activities would be most helpful to include? Select all that apply. A. Smoking cessation B. Cholesterol screening C. BP screening D. Early warning signs of a stroke E. Education on food high in vitamin K F. Importance of taking aspirin daily if having a history of sinus tachycardia

ANS: A, B, C, D Rationale: Smoking, high cholesterol, and hypertension are all modifiable risk factors. Smoking cessation and lowering BP and cholesterol help to prevent strokes and would be beneficial to include. Education on the early warning signs of stroke can help patients to seek medical care early, reducing the effect of the stroke. Education on foods high in vitamin K is important for patients on anticoagulants but does not relate to stroke awareness and prevention. Aspirin or anticoagulants are often prescribed for patients who have atrial fibrillation, not sinus tachycardia.

Which staff would be included in the care team at a certified stroke center? Select all that apply. A. Radiologist B. Neurologist C. Registered nurse D. Radiologic technician E. Emergency physician F. Patient care technician

ANS: A, B, C, D Rationale: The American Heart Association recommends that acute care facilities have the following members on their stroke team: registered nurse (RN), neurologist, radiologist, and radiologic technician. The emergency physician will activate the stroke team but not be a part of it. A patient care technician can be delegated tasks by the RN but only if needed.

Which tests would be of the greatest benefit to obtain information about cerebral blood flow in a patient who had a stroke? Select all that apply. A. Duplex scanning B. Electroencephalogram (EEG) C. Digital subtraction angiography D. Transcranial Doppler ultrasonography E. MRI

ANS: A, C, D Rationale: Duplex scanning, digital subtraction angiography, and transcranial Doppler ultrasonography are used to assess cerebral blood flow. An EEG would determine the electrical activity of the brain, not the cerebral blood flow. An MRI is an important diagnostic test that can rapidly distinguish between ischemic and hemorrhagic stroke. It helps to determine the size and location of the stroke and treatment options but does not assess cerebral blood flow.

While doing a neurologic assessment of a patient who sustained a thrombotic stroke, the nurse records the score of a patient as 40 on a National Institutes of Health Stroke Scale (NIHSS). Which interpretation does this score indicate? A. Minor stroke B. Severe stroke C. Moderate stroke D. No stroke symptoms

ANS: B Rationale: According to the NIHSS scale, a score of 40 indicates severe stroke. Minor and moderate strokes have scores below 40. A score of 0 indicates that the patient has no stroke symptoms.

A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours. What topic should the nurse anticipate teaching the patient? A. tPA B. Aspirin C. Warfarin D. Nimodipine

ANS: B Rationale: After a transient ischemic attack, patients typically are started on medications such as aspirin to inhibit platelet function and decrease stroke risk. tPA is used for acute ischemic stroke. Warfarin is usually used for patients with atrial fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage.

The nurse finds that the patient is unable to recognize familiar objects after a stroke. Which term would the nurse chart in the patient's medical record? A. Alexia B. Agnosia C. Aphasia D. Agraphia

ANS: B Rationale: Agnosia is the inability to recognize familiar objects by sight, touch, or hearing. Aphasia is difficulty in speaking or understanding speech. Alexia is difficulty reading. Agraphia is difficulty writing.

Which artery has a defect that is related to the cause of aphasia in a patient with a stroke? A. Vertebral artery B. Middle cerebral artery C. Anterior cerebral artery D. Posterior cerebral artery

ANS: B Rationale: Aphasia is caused by a defect in the middle cerebral artery. A defect in the vertebral artery may lead to cranial nerve deficits or coma. Defects in the anterior cerebral artery may cause motor or sensory deficits. A defect in the posterior cerebral artery may result in visual hallucinations or motor deficits.

If blood flow to the brain is interrupted, how quickly does cellular death occur? A. 2 minutes B. 5 minutes C. 30 minutes D. 30 seconds

ANS: B Rationale: Cellular death occurs within 5 minutes of a disruption in blood flow. Neurologic metabolism is altered in 30 seconds when the blood flow to the brain is interrupted. Metabolism stops in 2 minutes. Cellular death occurs much more quickly than in 30 minutes.

Which diagnostic test determines cerebral blood flow? A. Echocardiography B. Cerebral angiography C. Magnetic resonance angiography D. CT angiography

ANS: B Rationale: Cerebral angiography is performed to assess cerebral blood flow. Cerebral angiography helps to find blood vessel blockages present in the head and neck. Echocardiography is performed for cardiac assessment. Magnetic resonance angiography and CT angiography are performed for the diagnosis of a stroke and to assess the extent of involvement.

Which diagnostic study is the most reliable to identify the source of a subarachnoid hemorrhage? A. Cardiac imaging B. Cerebral angiography C. Magnetic resonance angiography D. CT angiography

ANS: B Rationale: Cerebral angiography is the most reliable diagnostic study to identify the source of subarachnoid hemorrhage. This test helps to identify cervical and cerebrovascular occlusions. Cardiac imaging, magnetic resonance angiography, and CT angiography are not as definitive for identifying the source of subarachnoid hemorrhage.

What will the nurse tell the patient who has cerebral atherosclerosis about taking clopidogrel (Plavix)? A. Monitor and record the blood pressure daily. B. Call the health care provider if stools are tarry. C. Clopidogrel will dissolve clots in the cerebral arteries. D. Clopidogrel will reduce cerebral artery plaque formation.

ANS: B Rationale: Clopidogrel inhibits platelet function and increases the risk for gastrointestinal bleeding, so patients should be advised to notify the health care provider about any signs of bleeding. The medication does not lower blood pressure, decrease plaque formation, or dissolve clots.

Several weeks after a stroke, a 50-yr-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention should be planned to begin an effective bladder training program? A. Limit fluid intake to 1200 mL daily to reduce urine volume. B. Assist the patient onto the bedside commode every 2 hours. C. Perform intermittent catheterization after each voiding to check for residual urine. D. Use an external "condom" catheter to protect the skin and prevent embarrassment.

ANS: B Rationale: Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full bladder. A 1200-mL fluid restriction may lead to dehydration. Intermittent catheterization and use of a condom catheter are appropriate in the acute phase of stroke but should not be considered solutions for long-term management because of the risks for urinary tract infection and skin breakdown.

Which information would the nurse include in a teaching plan about the onset of embolic stroke? A. Embolic stroke rarely recurs. B. Embolic stroke occurs rapidly. C. Embolic stroke renders the patient unconscious. D. It is common to have a warning sign with an embolic stroke.

ANS: B Rationale: Embolic stroke often occurs rapidly, whereby accommodation toward developing collateral circulation becomes difficult. It is not uncommon for embolic stroke to recur, unless the underlying causes are treated aggressively. During an embolic stroke, the patient may experience a headache but does not lose consciousness. Warning signs are less common with embolic than with thrombotic stroke.

A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which response by the nurse is accurate? A. "The diseased portion of the artery is replaced with a synthetic graft." B. "The obstructing plaque is surgically removed from inside an artery in the neck." C. "A wire is threaded through an artery in the leg to the clots in the carotid artery, and clots are removed." D. "A catheter with a deflated balloon is positioned at the narrow area, and the balloon flattens the plaque."

ANS: B Rationale: In a carotid endarterectomy, the carotid artery is incised, and the plaque is removed. The response beginning, "The diseased portion of the artery is replaced" describes an arterial graft procedure. The answer beginning, "A catheter with a deflated balloon is positioned at the narrow area" describes an angioplasty. The final response beginning, "A wire is threaded through the artery" describes the mechanical embolus removal in cerebral ischemia (MERCI) procedure.

The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse? A. The pulse rate is 102 beats/min. B. The patient has difficulty speaking. C. The blood pressure is 144/86 mm Hg. D. There are fine crackles at the lung bases.

ANS: B Rationale: Small emboli can occur during carotid artery angioplasty and stenting, and the aphasia indicates a possible stroke during the procedure. Slightly elevated pulse rate and blood pressure are not unusual because of anxiety associated with the procedure. Fine crackles at the lung bases may indicate atelectasis caused by immobility during the procedure.

A 70-yr-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? A. Take the patient's blood pressure. B. Check the respiratory rate and effort. C. Assess the Glasgow Coma Scale score. D. Send the patient for a computed tomography (CT) scan.

ANS: B Rationale: The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, and circulation) are completed.

Which information about the patient who had a subarachnoid hemorrhage is most important to communicate to the health care provider? A. The patient reports having a stiff neck. B. The patient's blood pressure (BP) is 90/50 mm Hg. C. The patient reports a severe and unrelenting headache. D. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).

ANS: B Rationale: To prevent cerebral vasospasm and maintain cerebral perfusion, BP needs to be maintained at a level higher than 90 mm Hg systolic after a subarachnoid hemorrhage. A low BP or drop in BP indicates a need to administer fluids and/or vasopressors to increase the BP. An ongoing headache, RBCs in the CSF, and a stiff neck are all typical clinical manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the health care provider.

Which instructions would the nurse give a patient about methods to reduce the risk of having a stroke? Select all that apply. A. Limit fluid and fiber intake. B. Eat a diet low in saturated fats. C. Decrease level of physical exercise. D. Maintain a normal BP. E. Limit consumption of alcohol to moderate levels.

ANS: B, D, E Rationale: Alcoholics and people with hypertension are prone to strokes. Hence, alcohol consumption should be limited, a diet low in fat should be consumed, and BP should be maintained. Also, physical exercise and adequate fluid and fiber intake will decrease the risk of stroke and should be promoted.

Which deficit is associated with left-hemispheric stroke? 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

ANS: C Patients with a left-hemispheric stroke are commonly 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-hemispheric stroke.

Which finding is consistent with a left-hemispheric stroke? A. Impaired judgment B. Unilateral weakness of the left extremities C. Unilateral weakness of the right extremities D. Spatial-perceptual deficits

ANS: C Rationale: A patient with a left-hemispheric stroke will have unilateral weakness of the right extremities. A patient with right-hemispheric stroke will have impaired judgment, unilateral weakness of the left extremities, and spatial-perceptual deficits.

A patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving a prescribed dose of aspirin? A. The patient has dysphasia. B. The patient has atrial fibrillation. C. The patient reports that symptoms began with a severe headache. D. The patient has a history of brief episodes of right-sided hemiplegia.

ANS: C Rationale: A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack are not contraindications to aspirin use.

The patient was exhibiting symptoms of a stroke for two hours before the symptoms resolved. Which condition may this patient have experienced? A. Embolic brain stroke B. Acute brain infarction C. Transient ischemic attack D. Subarachnoid hemorrhage

ANS: C Rationale: A transient ischemic attack is a transient episode of neurologic symptoms without acute brain infarction. Symptoms typically last less than one hour. With acute brain infarction, cell death occurs. An embolic brain stroke is associated with a clot to the brain, which causes permanent damage. Subarachnoid hemorrhage is bleeding in the subarachnoid area.

The nurse is caring for a patient who has been experiencing stroke symptoms for 60 minutes. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/VN)? A. Assess the patient's gag and cough reflexes. B. Determine when the stroke symptoms began. C. Administer the prescribed short-acting insulin. D. Infuse the prescribed IV metoprolol (Lopressor).

ANS: C Rationale: Administration of subcutaneous medications is included in LPN/VN education and scope of practice. The other actions require more education and scope of practice and should be done by the registered nurse (RN).

Which factor improves cerebral blood flow? A. An increase in blood viscosity B. A decrease in carbon dioxide levels C. An increase in hydrogen ion concentration D. A high partial pressure of arterial oxygen

ANS: C Rationale: An increase in hydrogen ion concentration results in increased cerebral blood flow. A decrease in blood viscosity will increase cerebral blood flow. An increase in carbon dioxide levels results in increased cerebral blood flow. A partial pressure of oxygen in arterial blood (PaO2) less than 50 mmHg increases the cerebral blood flow.

A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the patient says, "I don't need the aspirin today. I don't have a fever." Which action should the nurse take? A. Document that the patient refused the aspirin. B. Tell the patient that the aspirin is used to prevent a fever. C. Explain that the aspiring is ordered to decrease stroke risk. D. Call the health care provider to clarify the medication order.

ANS: C Rationale: Aspirin is ordered to prevent stroke in patients who have experienced TIAs. Documentation of the patient's refusal to take the medication is an inadequate response by the nurse. There is no need to clarify the order with the health care provider. The aspirin is not ordered to prevent aches and pains.

A patient admitted with possible stroke has been aphasic for 3 hours and has a current blood pressure (BP) of 174/94 mm Hg. Which order by the health care provider should the nurse question? A. Keep head of bed elevated at least 30 degrees. B. Infuse normal saline intravenously at 75 mL/hr. C. Start a labetalol drip to keep BP less than 140/90 mm Hg. D. Begin tissue plasminogen activator (tPA) intravenously per protocol.

ANS: C Rationale: Because elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if mean arterial pressure (MAP) is greater than130 mm Hg or systolic pressure is greater than 220 mm Hg. Fluid intake should be 1500 to 2000 mL/day to maintain cerebral blood flow. The head of the bed should be elevated to at least 30 degrees unless the patient has symptoms of poor tissue perfusion. tPA may be administered if the patient meets the other criteria for tPA use.

A left-handed patient with left-sided hemiplegia has difficulty feeding himself. Which intervention should the nurse include in the plan of care? A. Provide a wide variety of food choices. B. Provide oral care before and after meals. C. Assist the patient to eat with the right hand. D. Teach the patient the "chin-tuck" technique.

ANS: C Rationale: Because the patient has difficulty feeding himself, the appropriate interventions will focus on teaching the patient to use the right hand for self-feeding. The other interventions are appropriate for patients with other etiologies for the imbalanced nutrition.

An experienced nurse is teaching a novice nurse about interventions for a patient with a stroke. Which statement by the novice nurse indicates a need for further teaching? A. "I should maintain a calm and relaxing environment." B. "I should refrain from scolding the patient during an emotional outburst." C. "I should refrain from distracting the patient during a sudden emotional outburst." D. "I should educate the patient and the family about emotional outbursts after stroke."

ANS: C Rationale: Distraction during emotional outbursts is important to help the patient to overcome the situation. A calm and relaxing environment should be maintained to prevent any atypical behavior. Scolding during emotional outbursts should be avoided because the patient is unable to control the feelings. After a stroke, it is important to educate the patient and the family members about emotional outbursts.

Which intervention should the nurse include in the plan of care for a patient with new right-sided homonymous hemianopsia after a stroke? A. Apply an eye patch to the right eye. B. Approach the patient from the right side. C. Place needed objects on the patient's left side. D. Teach the patient that the left visual deficit will resolve.

ANS: C Rationale: During the acute period, the nurse should place objects on the patient's unaffected side. Because there is a visual defect in the right half of each eye, an eye patch is not appropriate. The patient should be approached from the left side. The visual deficit may not resolve, although the patient can learn to compensate for the defect.

A patient with a history of rheumatic heart disease arrives in the emergency department and informs the nurse of sudden loss of strength in the left arm without pain. The patient is unable to lift the arm and says that it "just fell." Which condition would the nurse suspect? A. Myopathy B. Fibromyalgia C. Embolic stroke D. Carpal tunnel syndrome

ANS: C Rationale: Embolic stroke occurs when an embolus lodges in and occludes a cerebral artery, resulting in infarction and edema of the area supplied by the involved vessel. Rheumatic heart disease is one cause of embolic stroke in young to middle-aged adults. Fibromyalgia presents as stiffness and pain in a particular part of the body. If there is no stiffness and pain, myopathy can be ruled out. The most common symptoms of carpal tunnel syndrome are tingling, numbness, weakness, or pain felt in the fingers or, less commonly, in the palm. Symptoms most often occur in the parts of the hand supplied by the median nerve: the thumb, index finger, middle finger, and half of the ring finger.

A patient was brought to the emergency department with a sudden onset of a severe headache different from any other headache previously experienced. Which type of stroke is most likely occurring based on these symptoms? A. Embolic stroke B. Thrombotic stroke C. Hemorrhagic stroke D. Transient ischemic attack (TIA)

ANS: C Rationale: Headache is common in a patient who has a hemorrhagic stroke, either 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.

Which stroke risk factor for a 48-yr-old male patient in the clinic is most important for the nurse to address? A. The patient is 25 pounds above the ideal weight. B. The patient drinks a glass of red wine with dinner daily. C. The patient's usual blood pressure (BP) is 170/94 mm Hg. D. The patient works at a desk and relaxes by watching television.

ANS: C Rationale: Hypertension is the single most important modifiable risk factor. People who drink more than 1 (for women) or 2 (for men) alcoholic beverages a day may increase their risk for hypertension. Physical inactivity and obesity contribute to stroke risk but not as much as hypertension.

A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first? A. Complete blood count (CBC) B. Chest radiograph (chest x-ray) C. Computed tomography (CT) scan D. 12-Lead electrocardiogram (ECG)

ANS: C Rationale: Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 4.5 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the less brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.

Which deficit associated with the anterior cerebral artery would the nurse expect to find in a patient who had a stroke? A. Diplopia B. Dysphagia C. Rooting reflex D. Visual hallucination

ANS: C Rationale: Rooting reflex is a deficit linked with the anterior cerebral artery during stroke. Diplopia and dysphagia are deficits that are linked to the vertebral artery in the occurrence of a stroke. Visual hallucination is a deficit linked with posterior cerebral artery during stroke.

Which type of stroke correlates with the clinical manifestations of a severe headache, hypertension, vomiting, dysarthria, and eye movement disturbances? A. Embolic stroke B. Thrombotic stroke C. Intracerebral hemorrhage D. Subarachnoid hemorrhage

ANS: C Rationale: Symptoms such as headaches, high BP, vomiting, dysarthria, and eye-movement disturbances indicate intracerebral hemorrhage. An embolic stroke is mostly related to heart conditions such as atrial fibrillation, myocardial infarction, and infective endocarditis. A thrombotic stroke has the clinical manifestation of decreased level of consciousness in the first 24 hours. Clinical manifestations such as stiff neck and cranial nerve deficits indicate a subarachnoid hemorrhage.

A patient will attempt oral feedings for the first time after having a stroke. After assessing the gag reflex, what action should the nurse take? A. Order a varied pureed diet. B. Assess the patient's appetite. C. Assist the patient into a chair D. Offer the patient a sip of juice.

ANS: C Rationale: The patient should be as upright as possible before attempting to feed to make swallowing easier and decrease aspiration risk. To assess swallowing ability, the nurse should initially offer water or ice to the patient. Pureed diets are not recommended because the texture is too smooth. The patient may have a poor appetite, but the oral feeding should be attempted.

What concern should the nurse anticipate for a patient who had a right hemisphere stroke? A. Right-sided hemiplegia B. Speech-language deficits C. Denial of deficits and impulsiveness D. Depression and distress about disability

ANS: C Rationale: The patient with right-sided brain damage typically denies any deficits and has poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability.

What topic should the nurse anticipate teaching a patient who had a brief episode of tinnitus, diplopia, dysarthria with no residual effects? A. Cerebral aneurysm clipping B. Heparin intravenous infusion C. Oral low-dose aspirin therapy D. Tissue plasminogen activator (tPA)

ANS: C Rationale: The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent a stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA.

The home health nurse is caring for an 81-yr-old who had a stroke 2 months ago. Based on patient information shown in the accompanying figure, which action should the nurse take? History: * Well controlled type 2 diabetes for 10 years * Married 45 years; spouse has heart failure and chronic obstructive pulmonary disease Physical Assessment: * Oriented to time, place, person * Speech clear * Minimal left leg weakness Physical/Occupational Therapy * Uses cane with walking * Spouse does household cleaning and cooking and assists patient with bathing and dressing A. Teach about preventing hypoglycemia. B. Begin processes to obtain a wheelchair. C. Provide support to the spouse caregiver. D. Remind the patient to take prescribed medications.

ANS: C Rationale: The spouse's household and patient care responsibilities, in combination with chronic illnesses, indicate a high risk for caregiver role strain. The nurse should take appropriate actions to provide support to the souse caregiver. The data about the control of the patient's diabetes indicates that hypoglycemia and medication adherence are not a current concern.

During change of shift report, a nurse is told that a patient has an occluded left posterior cerebral artery. What finding should the nurse anticipate? A. Dysphasia B. Confusion C. Visual deficits D. Poor judgment

ANS: C Rationale: Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with middle cerebral artery involvement. Cognitive deficits and changes in judgment are more typical of anterior cerebral artery occlusion.

A 63-yr-old patient who began experiencing right arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol? (Put a comma and a space between each answer choice [A, B, C, D].) A. Obtain CT scan without contrast. B. Infuse tissue plasminogen activator (tPA). C. Administer oxygen to keep O2 saturation >95%. D. Use National Institute of Health Stroke Scale to assess patient.

ANS: C, D, A, B Rationale: The initial actions should be those that help with airway, breathing, and circulation. Baseline neurologic assessments should be done next. A CT scan will be needed to rule out hemorrhagic stroke before tPA can be administered.

The patient recovering from a stroke who is confined to bed for most of the day is at risk for which condition? A. Fatigue B. Malnutrition C. Dehydration D. Constipation

ANS: D Rationale: A patient with poor physical mobility will have problems with constipation due to immobility and weak abdominal muscles. Fatigue is related to participation in physical activity. Malnutrition and dehydration are related to access to food and the ability to feed oneself.

A patient with a left-brain stroke suddenly bursts into tears when family members visit. How should the nurse respond? A. Use a calm voice to ask the patient to stop the crying behavior. B. Explain to the family that depression is normal following a stroke. C. Have the family members leave the patient alone for a few minutes. D. Teach the family that emotional outbursts are common after strokes.

ANS: D Rationale: Patients who have left-sided brain stroke are prone to emotional outbursts that are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient's outburst suggests that depression is not the major cause of the behavior. The family should stay with the patient. The crying is not within the patient's control. Asking the patient to stop will lead to embarrassment.

A patient being admitted with a stroke has right-sided facial drooping and right-sided arm and leg paralysis. Which finding should the nurse expect? A. Impulsive behavior B. Right-sided neglect C. Hyperactive left-sided tendon reflexes D. Difficulty comprehending instructions

ANS: D Rationale: Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with comprehension and use of language. The left-side reflexes are likely to be intact. Impulsive behavior and neglect are more likely with a right-side stroke.

Which assessment would the nurse teach a patient to report as part of the warning signs of stroke, using the mnemonic FAST? A. Footdrop B. Arm strength C. States disoriented D. Facial drooping

ANS: D Rationale: The FAST mnemonic, a quick and easy way to remember the signs of stroke according to the American Stroke Association, include FACE drooping, ARM weakness, SPEECH difficulties, and TIME. States disoriented, footdrop, and arm strength are not specific to the FAST mnemonic.

Which mechanism protects the brain and promotes its functioning? A. Collateral circulation B. Intracranial pressure C. Neurologic metabolism D. Cerebral autoregulation

ANS: D Rationale: The brain is normally protected from changes in mean systemic arterial BP over a range from 50 to 150 mmHg by a mechanism known as cerebral autoregulation. This involves changes in the diameter of cerebral blood vessels in response to changes in pressure so that the blood flow to the brain stays constant. The brain is well protected and functions best with cerebral autoregulation. Collateral circulation, or alternative routes of blood flow, may develop over time to compensate for a decrease in cerebral blood flow. The neurologic metabolism is a continuous supply of oxygen and glucose for neurons to function. Intracranial pressure influences cerebral blood flow and is affected by volume and pressure changes in the brain.

A patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. Health records show a history of several transient ischemic attacks (TIAs). What should the nurse anticipate for this patient? A. Surgical endarterectomy B. Transluminal angioplasty C. Intravenous heparin drip administration D. Tissue plasminogen activator (tPa) infusion

ANS: D Rationale: The patient's history and clinical manifestations suggest an acute ischemic stroke, and a patient who is seen within 4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is having an acute ischemic stroke.

A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? A. The patient's speech is difficult to understand. B. The patient's blood pressure (BP) is 144/90 mm Hg. C. The patient takes a diuretic because of a history of hypertension. D. The patient has atrial fibrillation and takes warfarin (Coumadin).

ANS: D Rationale: The use of warfarin probably contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patient's care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated.

Which risk factors would the nurse include in a teaching plan when instructing a patient about modifiable risk factors for stroke? A. Age B. Gender C. Heredity D. Smoking

ANS: D Rationale: Smoking is a modifiable risk factor. Age, gender, and heredity are not modifiable.

Which neurologic factor would the nurse assess and record for a patient who had a stroke? A. Speech B. Mobility C. Respiratory function D. Level of consciousness

D. Level of consciousness Rationale: The nurse will assess the patient's level of consciousness and record it as a neurologic finding. Though related to neurologic functioning, speech, mobility, and respiratory function are motor function assessments.