NUR 260 - Neuro Exam 3

Increased distractibility; left or right hemispheric stroke?

Right

Lack of awareness of deficits; left or right hemispheric stroke?

Right

Spatial-perceptual deficits; left or right hemispheric stroke?

Right

List four criteria that would prevent the administration of tPA for an ischemic stroke:

- An elevated blood pressure: systolic of more than 185 mm Hg and a diastolic of more than 110 mm Hg; - a recent or prior stroke - major surgery or serious head injury

The nurse plays a critical role in the initial work-up of a patient with acute stroke symptoms. An immediate decision is to determine if the stroke is ischemic or hemorrhagic. Although there is overlap in some motor, sensory, and cognitive changes, hemorrhagic strokes can be identified by some specific signs. Which of the following signs are consistent with a hemorrhagic stroke? Select all that apply. a. Vomiting b. Numbness or weakness of an extremity c. Sudden, severe headache d. Altered level of consciousness e. Seizures f. Loss of balance

- Vomiting - Sudden, severe headache - Seizures. RATIONALE: These three signs are usually diagnostic of a hemorrhagic stroke. The other signs can occur with both hemorrhagic and ischemic stroke.

A nurse knows that, for a patient with an ischemic stroke, tPA is contraindicated if the blood pressure reading is: a. 170 mm Hg/ 105 mm Hg b. 175 mm Hg/ 100 mm Hg c. 185 mm Hg/ 110 mm Hg d. 190 mm Hg/ 120 mm Hg

190 mm Hg/ 120 mm Hg RATIONALE: Elevated blood pressure (systolic > 185; diastolic > 110 mm Hg) is a contraindication to tPA.

When caring for a patient with an intracerebral hemorrhagic stroke, the nurse knows to immediately report the following intracranial pressure (ICP) reading, which is an indicator that treatment is needed. What is that reading? a. 5 mm Hg b. 10 mm Hg c. 15 mm Hg d. 20 mm Hg

20 mm Hg RATIONALE: The normal ICP reading is 7 to 15 mm Hg. Treatment is needed when the ICP rises to 20 to 25 mm Hg.

Evaluating the level of consciousness using the Glasgow Coma Scale is an essential nursing assessment for a patient who has had an intracerebral hemorrhage. Which of the following scores would indicate the need for immediate intubation? a. 15 b. 12 c. 10 d. 8

8. RATIONALE: Scores on the Glasgow Coma Scale range from 3 to 15. A score of 8 or less is cause for immediate intubation.

Describe a transient ischemic attack (TIA).

A transient ischemic attack, or TIA : a brief episode of neurological dysfunction resulting from focal cerebral ischemia not associated with permanent cerebral infarction. TIAs have often been referred to as "mini-strokes" or warning strokes since the causative process is likely to recur (causing a stroke) if no interventions are made.

The two major causes for an interruption of cerebral blood flow causing a stroke are _________________ and _________________.

An occluded artery that deprives blood flow to a part of the brain and (2) a ruptured artery that causes bleeding in or around the brain.

There are five causes of an intracranial aneurysm. Name three:

Answer should include three of the following: atherosclerosis, a congenital defect of the vessel wall, hypertensive vascular disease, head trauma, and advancing age.

Name the test that is used to distinguish a hemorrhagic stroke from an ischemic stroke:

CAT scan

After the patient has received tPA, the nurse knows to check vital signs every 30 minutes for 6 hours. Which of the following readings would require calling the provider? a. Heart rate of 100 b. Respiration of 22 c. Systolic pressure of 180 mm Hg d. Diastolic pressure of 110 mm Hg

Diastolic pressure of 110 mm Hg RATIONALE: A diastolic pressure reading of over 105 mm Hg warrants notifying the health care provider. The other choices are within normal range. Refer to Table 47-5 in the text.

List the two main presenting symptoms of a hemorrhagic stroke: _________________ and _________________.

Exploding headache and decreased level of consciousness

Name the four immediate complications of an acute hemorrhagic stroke:

Extension of bleeding causing increased ICP, acute hydrocephalus, potential for herniation, and secondary brain injury

Describe a hemorrhagic stroke:

Hemorrhagic strokes include bleeding into the brain tissue (parenchyma), the ventricles, or the subarachnoid space. Normal brain metabolism is disrupted when blood outside the vasculature forms a mass that compresses adjacent brain tissue, causing increased intracranial pressure, secondary hemorrhage, and ischemia, and possibly herniation. If blood extends into the ventricles, it can cause acute hydrocephalus.

A nurse practitioner provides health teaching to a patient who has difficulty managing hypertension. This patient is at an increased risk of which type of stroke ? a. Intracerebral hemorrhage b. Subarachnoid hemorrhage c. Hemorrhage due to an aneurysm d. Arteriovenous malformation

Intracerebral hemorrhage RATIONALE: About 80% of hemorrhagic strokes are intracerebral, and they are caused primarily by uncontrolled hypertension.

Altered intellectual ability; left or right hemispheric stroke?

Left

Aphasia; left or right hemispheric stroke?

Left

Explain how recombinant tissue plasminogen activator (r-tPA) works.

Recombinant tissue plasminogen activator (rtPA) is currently the only FDA-approved drug for acute ischemic stroke within a 3-hour window of symptom onset. tPA binds to fibrin and converts plasminogen to plasmin, which is responsible for clot breakdown.

Impulsive behavior and poor judgment; left or right hemispheric stroke?

Right

Discuss the etiology of a stroke.

Stroke is a heterogeneous syndrome characterized by the onset of one or more focal neurologic deficits (corresponding to the affected area of the brain) caused by reduced cerebral blood flow that leads to brain cell death and functional disability.

Explain what is meant by the "zone of penumbra."

The "zone of penumbra" refers to an area of low cerebral blood flow that exists around the area of infarction. It is ischemic brain tissue that may be salvaged with timely intervention.

six common symptoms of a stroke:

numbness or weakness of the face, arm, or leg, especially on one side of the body; confusion or change in mental status; trouble speaking or understanding speech; visual disturbances; difficulty walking, dizziness, or loss of balance or coordination; and a sudden, severe headache.