PrepU Ch67 Cerebrovascular Disorders
Which of the following, if left untreated, can lead to an ischemic stroke? A. A fib B. Cerebral aneurysm C. ateriovenous malformation (AVM) D. Ruptured cerebral arteries
A fib
Which term refers to the failure to recognize familiar objects perceived by the senses? Agnosia Agraphia Apraxia Perseveration
Agnosia
The nurse is caring for a client with aphasia. Which strategy will the nurse use to facilitate communication with the client? Speaking loudly Establishing eye contact Avoiding the use of hand gestures Speaking in complete sentences
Establishing eye contact
Which of the following antiseizure medication has been found to be effective for post-stroke pain? Lamotrigine (Lamictal) Phenytoin (Dilantin) Carbamazepine (Tegretol) Topiramate (Topamax)
Lamotrigine (Lamictal)
Which clinical manifestation would be exhibited by a client following a hemorrhagic stroke of the right hemisphere? Inability to move the right arm Neglect of the left side Neglect of the right side Expressive aphasia
Neglect of the left side
What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke?
left visual field deficit
The client with a cerebral aneurysm asks the nurse, "What's the big fuss over a headache?" Which is the best response from the nurse regarding to a cerebral aneurysm? "Don't worry. The aneurysm has probably been there since birth." "The headache can be an indication that the aneurysm is growing." "A headache means your aneurysm is leaking blood into the brain." "Your physician wants to evaluate the location and condition of the aneurysm."
"Your physician wants to evaluate the location and condition of the aneurysm."
The nurse knows that symptoms associated with a TIA, usually a precursor of a future stroke, usually subside in what period of time?
1 hr A transient ischemic attack (TIA) is a neurologic deficit typically lasting less than 1 hour. A TIA is manifested by a sudden loss of motor, sensory, or visual function. The symptoms result from temporary ischemia (impairment of blood flow) to a specific region of the brain; however, when brain imaging is performed, there is no evidence of ischemia.
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? Cholesterol-lowering drugs Anticoagulant therapy Monthly prothrombin levels Carotid endarterectomy
Anticoagulant therapy
Which term refers to the inability to perform previously learned purposeful motor acts on a voluntary basis?
Apraxia
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?
Cerebral aneurysm
A client's spouse relates how the client reported a severe headache and then was unable to talk or move their right arm and leg. After diagnostics are completed and the client is admitted to the hospital, when would basic rehabilitation begin? immediately in 2 to 3 days after 1 week upon transfer to a rehabilitation unit
Immediately
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? Intracerebral hemorrhage Subarachnoid hemorrhage Hemorrhage due to an aneurysm Arteriovenous malformation
Intracerebral hemorrhage About 80% of hemorrhagic strokes are intracerebral, and they are caused primarily by uncontrolled HTN
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? Ischemic Hemorrhagic Right-sided Left-sided
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.
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 action? Cluster headaches can cause severe debilitating pain. Migraines often coincide with menstrual cycle. Tension headaches are easier to treat. Headaches are the most common type of reported pain.
Migraines often coincide with menstrual cycle. due to changes in reproductive hormones
A client with a cerebrovascular accident (CVA) is having difficulty with eating food on the plate. Which is the best priority nursing action to be taken? A. Perform a vision field assessment. B. Reposition the tray and plate. C. Assist the client with feeding. D. Know this is a normal finding for CVA.
Perform a vision assessment The nurse should perform a vision field assessment to evaluate the client for hemianopia. This finding could indicate damage to the visual area of the brain as a result of evolving CVA. Repositioning the tray and assisting with feeding would not be the best nursing action until new finding has been evaluated. Hemianopia can be associated with a CVA but, when presenting as a new finding, should be evaluated and reported immediately.
The nurse is completing an assessment on a client with a history of migraines. The nurse would identify which of the following factors as a possible trigger for a migraine headache? Select all that apply. Red wine Nausea Menstruation Exposure to flashing light Change in environmental temperature Prolonged positioning
Red wine Menstruation Exposure to flashing light
The geriatric advanced practice nurse (APN) is doing client teaching with a client who has had a cerebrovascular accident (CVA) and the client's family. One concern the APN addresses is a potential for falls related to the CVA and resulting muscle weakness. What would be most important for the APN to include in teaching related to this concern? Leg exercises to strengthen muscle weakness. Need for support group due to decreased self image related to restricted mobility. Remove throw rugs and electrical cords from home environment. Use of tripod cane.
Remove throw rugs and electrical cords from home environment.
A nurse in a rehabilitation facility is coordinating the discharge of a client who is tetraplegic. The client, who is married and has two children in high school, is being discharged to home and will require much assistance. Who would the discharge planner recognize as being the most important member of this client's care team? A. Chaplain B. PT C. Spouse D. Home care nurse
Spouse
A patient having an acute stroke with no other significant medical disorders has a blood glucose level of 420 mg/dL. What significance does the hyperglycemia have for this patient? The patient has new onset diabetes. This is significant for poor neurologic outcomes. The patient has developed diabetes insipidus due to the location of the stroke. The patient has liver failure.
This is significant for poor neurologic outcomes. Hyperglycemia has been associated with poor neurologic outcomes in acute stroke and should be treated if the blood glucose is above 140 mg/dL
A nurse practitioner is presenting health information about strokes at a clinic. She mentions that there are five categories of strokes based on their origin. Which of the following is the category that has the highest incidence of strokes (30%)?
cryptogenic
A diagnostic test has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include honey thickened liquids. Which of the following is the priority nursing diagnosis for this client? Risk for Fluid Volume Deficit Risk for Electrolyte Imbalance Impaired Swallowing Altered Nutrition: Less Than Body Requirements
impaired swallowing
A nurse is instructing the spouse of a client who suffered a stroke about the use of eating devices the client will be using. During the teaching, the spouse starts to cry and states, "One minute he is laughing, and the next he's crying; I just don't understand what's wrong with him." Which statement is the best response by the nurse? A. This behavior is common in clients with stroke. Which does your spouse do more often? Laugh or cry?" B. "Emotional lability is common after a stroke, and it usually improves with time." C. "You seem upset, and it may be hard for you to focus on the teaching, I'll come back later." D. "You sound stressed; maybe using some stress management techniques will help."
"Emotional lability is common after a stroke, and it usually improves with time."
A patient is in the acute phase of an ischemic stroke. How long does the nurse know that this phase may last?
1 to 3 days
A patient is admitted via ambulance to the emergency room of a stroke center at 1:30 p.m. with symptoms that the patient said began at 1:00 p.m. Within 1 hour, an ischemic stroke had been confirmed and the doctor ordered tPA. The nurse knows to give this drug no later than what time? A. 2PM B 3PM C 4PM D 7PM
4PM Tissue plasminogen activator (tPA) must be given within 3 hours after symptom onset. Therefore, since symptom onset was 1:00 pm, the window of opportunity ends at 4:00 pm.
A nurse is caring for a client who has returned to his room after a carotid endarterectomy. Which action should the nurse take first? Ask the client if he has trouble breathing. Take the client's blood pressure. Ask the client if he has a headache. Place antiembolism stockings on the client.
Ask the client if he has trouble breathing.
A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to do perform which action? A. Comprehend spoken words B. Form understandable words C. Form understandable words and comprehend spoken words D.Speak at all
Form understandable words and comprehend spoken words
The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regimen, 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:
HTN
An emergency department nurse is interviewing a client who is presenting with signs of an ischemic stroke that began 2 hours ago. The client reports a history of a cholecystectomy 6 weeks ago and is taking digoxin, warfarin, and labetalol. What factor poses a threat to the client for thrombolytic therapy? A. INR greater than 2 B. 2 hour time period of the stroke C. Taking digoxin D. Surgery 6 weeks ago
INR greater than 2 The client is at risk for further bleeding if the international normalized ratio is greater than 2. Thrombolytic therapy must be initiated within 3 hours in clients with ischemic stroke. The client is not eligible for thrombolytic therapy if she has had surgery within 14 days. Digoxin and labetalol do not prohibit thrombolytic therapy.
A transcranial Doppler ultrasonography detects cerebral vasospasms in a client experiencing lethargy 8 days following a subarachnoid hemorrhage. The nurse anticipates which therapeutic intervention? Fluid restriction Nitroprusside IV Nimodipine PO Phenytoin IV
Nimodipine PO Meds may be effective in the treatment of vasospasm. Based on 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. The other interventions and medications are not used to treat vasospasms.
The nurse practitioner is able to correlate a patient's neurologic deficits with the location in the brain affected by ischemia or hemorrhage. For a patient with a left hemispheric stroke, the nurse would expect to see: Spatial-perceptual deficits. Left visual field deficit. Right-sided paralysis. Impulsive behavior.
Right-sided paralysis.
A patient suffering a stroke is having a difficult time swallowing. What would the nurse document this finding as?
dysphagia
Aneurysm rebleeding occurs most frequently during which time frame after the initial hemorrhage? First 12 hours First 24 hours First 48 hours First 72 hours
first 12 hours Aneurysm rebleeding occurs most frequently during the first 2-12 hours after the initial hemorrhage
Which is the most common motor dysfunction seen in clients diagnosed with stroke? Ataxia Diplopia Hemiplegia Hemiparesis
hemiplegia
Which terms refers to blindness in the right or left half of the visual field in both eyes?
homonymous hemianopsia
The nurse is participating in a health fair for stroke prevention. Which will the nurse say is a modifiable risk factor for ischemic stroke?
smoking
The nurse is preparing to administer tissue plasminogen activator (t-PA) to a patient who weighs 132 lb. The order reads 0.9 mg/kg t-PA. The nurse understands that 10% of the calculated dose is administered as an IV bolus over 1 minute, and the remaining dose (90%) is administered IV over 1 hour via an infusion pump. How many milligrams IV bolus over 1 minute will the nurse initially administer?
5.4
Which of the following is the chief cause of intracerebral hemorrhage (ICH)? Uncontrolled hypertension Diabetes Hypercholesterolemia Migraine headaches
Uncontrolled hypertension
When communicating with a client who has sensory (receptive) aphasia, the nurse should:
Use short simple sentences
difficulty if forming words
dysarthria
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?
left-sided cerebrovascular accident (CVA)
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? Diphenhydramine (Benadryl) Lioresal (Baclofen) Heparin Pregabalin (Lyrica)
Lioresal (Baclofen) Spasticity, particularly in the hand, can be a disabling complication after stroke. Botulinum toxin type A injected intramuscularly into wrist and finger muscles has been shown to be effective in reducing this spasticity (although the effect is temporary, typically lasting 2 to 4 months) Other treatments for spasticity may include stretching, splinting, and oral medications such as baclofen (Lioresal).
When providing teaching to a client who reports tension headaches, which of the following instructions would be most beneficial to prevent onset of symptoms? Apply cool or warm cloth to head or eyes. Eliminate use of bright lights when working. Avoid certain foods. Perform stretching exercises and frequent position change.
Perform stretching exercises and frequent position change. Tension headaches are often associated with prolonged tensed muscles. Application of cool or warm cloths and avoidance of bright lights may help to reduce the headache after occurrence. Avoiding certain foods may prevent migraine headaches, but it is not likely to prevent tension headaches.
A client with CVA is prescribed medication to treat the disorder. The client wants to know what other measures may help reduce CVA. Which is an accurate suggestion for the client? Increase body weight moderately Reduce hypertension and high blood cholesterol Increase intake of proteins and carbohydrates Increase hydration and the intake of fluids
Reduce hypertension and high blood cholesterol CVAs are prevented by reducing certain risk factors, such as hypertension, overweight, cardiac dysrhythmias like atrial fibrillation, and high blood cholesterol. Clients should not gain body weight. In addition, increased intake of proteins, carbohydrates, or fluids does not help reduce the risk of CVAs.
The provider diagnoses the patient as having had an ischemic stroke. The etiology of an ischemic stroke would include which of the following? A. Cardiogenic emboli B. Cerebral aneurysm C. Arteriovenous malformation D. Intracerebral hemorrhage
Cardiogenic emboli Aneurysms, hemorrhages, and malformations are all examples of a hemorrhagic stroke. An embolism can block blood flow, leading to ischemia.
A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the health care provider in the emergency department. Which is the origin of the client's symptoms? A. diabetes insipidus B. impaired cerebral circulation C. cardiac disease D. hypertension
impaired cerebral circulation TIAs involve the same mechanism as in the ischemic cascade, but symptoms are transient (< 24 hours) and there is no evidence of cerebral tissue infarction. The ischemic cascade begins when cerebral blood flow decreases to less than 25 mL/100 g/min and neurons are no longer able to maintain aerobic respiration. Thus, a TIA results directly from impaired blood circulation in the brain. Atherosclerosis, cardiac disease, hypertension, or diabetes can be risk factors for a TIA but do not cause it.
A 76-year-old male 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? Select all that apply. Balloon angioplasty of the carotid artery followed by stent placement Removal of the carotid artery Percutaneous transluminal coronary artery angioplasty Carotid endarterectomy Administration of tissue plasminogen activator
Balloon angioplasty of the carotid artery followed by stent placement Carotid endarterectomy If narrowing of the carotid artery by atherosclerotic plaques is the cause of the TIAs, a carotid endarterectomy (surgical removal of atherosclerotic plaque) could be performed. A balloon angioplasty of the carotid artery, a procedure similar to a percutaneous transluminal coronary artery angioplasty, may be performed alternatively to dilate the carotid artery and increase blood flow to the brain, followed by stent placement. The other options are not options to increase blood flow through the carotid artery to the brain
The nurse is caring for a client with a history of transient ischemic attacks (TIAs) and moderate carotid stenosis who has undergone a carotid endarterectomy. Which postoperative finding would cause the nurse the most concern? Neck pain rated 3 of 10 (on a 0 to 10 pain scale) Blood pressure 128/86 mm Hg Mild neck edema Difficulty swallowing
Difficulty swallowing The client's inability to swallow without difficulty would cause the nurse the most concern. Difficulty 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). Some edema in the neck after surgery is expected; however, extensive edema and hematoma formation can obstruct the airway. Emergency airway supplies, including those needed for a tracheostomy, must be available. The client's neck pain and mildly elevated blood pressure need to be addressed but would not cause the nurse the most concern. Hypotension is avoided to prevent cerebral ischemia and thrombosis. Uncontrolled hypertension may precipitate cerebral hemorrhage, edema, hemorrhage at the surgical incision, or disruption of the arterial reconstruction.
A client has a 12-year history of cluster headaches. After the client describes the characteristics of the head pain, the nurse begins to discuss its potential causes. What would the nurse indicate that the origin of the headaches is: unknown. muscular. vasodilating agents. endocrine.
unknown Although cluster headaches can be triggered by vasodilating agents, the cause of cluster headaches is unknown.
A 154-pound woman has been prescribed tPA (0.9 mg/kg) for an ischemic stroke. The nurse knows to give how many mg initially? 6.3 mg 7.5 mg 8.3 mg 10 mg
6.3 mg A person who weighs 154 lbs weighs 70 kg. To calculate total dosage, multiply 70 × 0.9 mg/kg = 63 mg. Ten percent of the calculated dose is given as an IV bolus over 1 minute. The remaining dose (90%) is given IV over 1 hour via an infusion pump. So initially the nurse gives 10% (6.3 mg) over 1 minute.
A nurse knows that, for a patient with an ischemic stroke, tPA is contraindicated if the blood pressure reading is higher than:
185 mm Hg/110 mm Hg
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? A thrombus formation at the site of the endarterectomy This is a normal occurrence after an endarterectomy and would not be a concern. Bleeding from the endarterectomy site Surgical wound infection
A thrombus formation at the site of the endarterectomy
A client diagnosed with a stroke is ordered to receive warfarin. 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 A. Dipyridamole B. Aspirin C. Clopidogrel D. Ticlopidine
Aspirin If warfarin is contraindicated, aspirin is the best option, although other medications may be used if both are contraindicated.
Which interventions would be recommended for a client with dysphagia? Select all that apply. A. Assist the client with meals. B. Place food on the affected side of the mouth. C. Allow ample time to eat. D. Test the gag reflex before offering food or fluids.
Assist the client with meals. Test the gag reflex before offering food or fluids. Allow ample time to eat.
Which of the following is the most common side effect of tissue plasminogen activator (tPA)? A. Bleeding B. HA C. IICP D. HTN
Bleeding Bleeding is the most common side effect of tPA. The patient is closely monitored for bleeding (at IV insertion sites, gums, urine/stools, and intracranially by assessing changes in level of consciousness). Headache, increased ICP, and hypertension are not side effects of tPA.
A client is following up after a visit to the emergency department where testing indicated that the client had suffered a transient ischemic attack. What lifestyle changes would the nurse include in teaching to prevent further reoccurrence? Select all that apply. High-dose aspirin Blood pressure control Weight loss Physical activity limitations Smoking cessation
Blood pressure control Weight loss Smoking cessation
A 45-year-old client presents to the ED reporting trouble speaking and numbness of the right arm and leg. The nurse suspects an ischemic stroke. Which insult or abnormality can cause an ischemic stroke? Cocaine use Arteriovenous malformation Trauma Intracerebral aneurysm rupture
Cocaine use Two classifications of ischemic strokes are cryptogenic strokes, which have no known cause, and strokes from other causes, such as illicit drug use, coagulopathies, migraine, and spontaneous dissection of the carotid or vertebral arteries. Cocaine is a potent vasoconstrictor and may result in a life-threatening reaction, even with the individual's first use of the drug. Arteriovenous malformations, trauma, and intracerebral aneurysm are associated with hemorrhagic strokes.
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 130 mm Hg D. Diastolic pressure of 110 mm Hg
Diastolic pressure of 110 mm Hg
A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? A. Heparin sodium B. Dexamethasone C. Methyldopa D. Phenytoin
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 healthcare provider may use dexamethasone (Decadron) to decrease cerebral edema and pressure, methyldopa (Aldomet) to reduce blood pressure, and phenytoin (Dilantin) to prevent seizures.
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? Positioning the client to prevent airway obstruction Keeping the client in one position to decrease bleeding Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess Maintaining the client in a quiet environment
Keeping the client in one position to decrease bleeding shouldn't keep pt in one position. carefully reposition at least q1hr pt needs to be positioned so that a patent airway can be maintained. Fluid admin must be closely monitored to prevent complications such as IICP. must be maintained in a quiet environment to decrease the risk of rebleeding.
A family member comes to the clinic to talk to the nurse about a client who has had a stroke on the right side of the brain. The family member is concerned because of the deficits the client is exhibiting. The nurse knows that when a client experiences a stroke on the right side of the brain, common deficits include what? Select all that apply. Left-sided hemiplegia Tendency to distractibility Impairment of long-term memory Hyperaware of deficits Neglect of objects and people on the left side
Left-sided hemiplegia Tendency to distractibility Neglect of objects and people on the left side
The nurse is caring for a client diagnosed with a hemorrhagic stroke. The nurse recognizes that which intervention is most important? A. Administering a stool softener B. Elevating the head of the bed to 30 degrees C. Maintaining a patent airway D. Monitoring for seizure activity
Maintain patent airway
After having a stroke, a patient has cognitive deficits. What are the cognitive deficits the nurse recognizes the patient has as a result of the stroke? Select all that apply. Poor abstract reasoning Decreased attention span Short- and long-term memory loss Expressive aphasia Paresthesias
Poor abstract reasoning Decreased attention span Short- and long-term memory loss
A nurse is caring for a client with a cerebral aneurysm. Which nursing interventions would be most useful to the nurse to avoid bleeding in the brain? Select all that apply. Report changes in neurologic status as soon as a worsening trend is identified. Use a well-lighted room for assessments every 2 hours. Follow the healthcare provider's orders to increase fluid volume. Maintain the head of the bed at 30 degrees. Avoid any activities that cause a Valsalva maneuver.
Report changes in neurologic status as soon as a worsening trend is identified. Maintain the head of the bed at 30 degrees. Avoid any activities that cause a Valsalva maneuver.
A client on your unit is scheduled to have intracranial surgery in the morning. Which nursing intervention helps to avoid intraoperative complications, reduce cerebral edema, and prevent postoperative vomiting? A. Restrict fluids before surgery. B. Administer prescribed medications. C. Administer preoperative sedation. D. Administer an osmotic diuretic.
Restrict fluids before surgery Before surgery, the nurse should restrict fluids to avoid intraoperative complications, reduce cerebral edema, and prevent postoperative vomiting. The nurse administers prescribed medications such as an anticonvulsant phenytoin, like Dilantin, to reduce the risk of seizures before and after surgery, an osmotic diuretic, and corticosteroids. Preoperative sedation is omitted.
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? seasonal changes reproductive hormone fluctuations specific food chemicals medications
Seasonal changes
The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient? High-Fowler's Prone Supine Semi-Fowler's
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.
A client is hospitalized when presenting to the emergency department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to his presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what? Left-sided stroke Right-sided stroke Cerebral aneurysm Transient ischemic attack
Transient ischemic attack A transient ischemic attack (TIA) is a sudden, brief attack of neurologic impairment caused by a temporary interruption in cerebral blood flow. Symptoms may disappear within 1 hour; some continue for as long as 1 day. When the symptoms terminate, the client resumes his or her presymptomatic state. The symptoms do not describe a left- or right-sided stroke or a cerebral aneurysm.
The nurse recognizes health promotion efforts to decrease the risk for ischemic stroke involve encouraging a healthy lifestyle, including eating fish no more than once a month. a low-fat, low-cholesterol diet and increased exercise. a high-protein diet and increased weight-bearing exercise. a low-cholesterol, low-protein diet and decreased aerobic exercise.
a low-fat, low-cholesterol diet and increased exercise Health promotion efforts to decrease the risk for ischemic stroke involve encouraging a healthy lifestyle, including a low-fat, low-cholesterol diet and increased exercise. Recent evidence suggests that eating fish 2+ times per week reduces the risk of thrombotic stroke for women.
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
A client is experiencing severe pain related to increased ICP. Which analgesic would be ordered for this client to help alleviate pain? codeine hydrocodone morphine fentanyl
codeine Avoid administering opioid analgesics, except codeine. Opioids interfere with accurate assessment of neurologic function because they constrict the pupils and depress LOC.
Which is a contraindication for the administration of tissue plasminogen activator (t-PA)? A. Intracranial hemorrhage B. Ischemic stroke C. Age 18 years or older D. Systolic blood pressure less than or equal to 185 mm Hg
intracranial hemorrhage Intracranial hemorrhage, neoplasm, and aneurysm are contraindications for t-PA. Clinical diagnosis of ischemic stroke, age 18 years or older, and a systolic blood pressure less than or equal to 185 mm Hg are eligibility criteria.
A client has experienced an ischemic stroke that has damaged the frontal lobe of his brain. Which of the following deficits does the nurse expect to observe during assessment?
limited attention span and forgetfulness Damage to the frontal lobe may impair learning capacity, memory, or other higher cortical intellectual functions. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and a lack of motivation. Damage to the motor neurons may cause hemiparesis, hemiplegia, and a change in reflexes. Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia.
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?
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).
symptoms of Korsakoff syndrome
personality disorder characterized by: Psychosis, disorientation, delirium, insomnia, and hallucinations
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. Vomiting Numbness or weakness of an extremity Sudden, severe headache Loss of balance Seizures
vomiting sudden, severe HA seziures These three signs are usually diagnostic of a hemorrhagic stroke. The other signs can occur with both hemorrhagic and ischemic stroke.
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 are highly variable, depending on the cardiovascular health of the client." "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." "Clinical manifestations of a stroke generally include aphasia, one-sided flaccidity, and trouble swallowing." "Clinical manifestations of a stroke depend on how quickly the clot can be dissolved."
"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." Clinical manifestations following a stroke are highly variable and depend on the area of the cerebral cortex and the affected hemisphere, the degree of blockage (total, partial), and the presence or absence of adequate collateral circulation. (Collateral circulation is circulation formed by smaller blood vessels branching off from or near larger occluded vessels.) Clinical manifestations of a stroke do not depend on the cardiovascular health of the client or how quickly the clot can be dissolved. Clinical manifestations of a stroke are not "general" but individual.
A client is prescribed sumatriptan for the treatment of migraine headache. Which client statement would indicate a need for additional teaching from the nurse? "I use this to prevent migraines." "I take this when I get a headache." "It constricts the blood vessels in my head." "It alleviates my sensitivity to light and sound."
"I use this to prevent migraines." Sumatriptan is a serotonin receptor agonist that stimulates serotonin receptors in the brain and causes vasoconstriction of the cerebral arteries and reduce/eliminate headaches and other symptoms associated with migraines. Sumatriptan is used during an attack and is not indicated for preventative migraine therapy.
A client recently experienced a stroke with accompanying left-sided paralysis. His family voices concerns about how to best interact with him. They report the client doesn't seem aware of their presence when they approach him on his left side. What advice should the nurse give the family?
"The client is unaware of his left side. You should approach him on the right side."
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?
A. severe exploding headache B. left-sided weakness C. slurred speech D. difficulty finding appropriate words 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.
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? A. Apply warm or cool cloths to the forehead or back of the neck. B. Maintain hydration by drinking eight glasses of fluid a day. C. Perform the Heimlich maneuver. D. Use pressure-relieving pads or a similar type of mattress.
Apply warm or cool cloths to the forehead or back of the neck. Warmth promotes vasodilation; cool stimuli reduce blood flow.
A nurse is reading a journal article about stroke and the underlying causes associated with this condition. The nurse demonstrates understanding of the information when identifying which subtype of stroke as being due to atrial fibrillation? large-artery thrombotic small, penetrating artery thrombotic cardio embolic cryptogenic
Cardio embolic Ischemic strokes are further divided into five subtypes, according to a mechanism-based classification system: large-artery thrombotic strokes (representing 20% of ischemic strokes); small, penetrating artery thrombotic strokes (25%); cardio embolic strokes (20%); cryptogenic strokes (strokes that cannot be attributed to any specific cause) (30%); and "other" (5%). Large-artery thrombotic strokes are caused by atherosclerotic plaques in the large blood vessels of the brain. Thrombus formation and occlusion can occur at the site of the atherosclerosis and result in ischemia and infarction (tissue death). Small, penetrating artery thrombotic strokes that affect one or more vessels and cause reduced blood flow are the most common type of ischemic stroke, typically caused by longstanding hypertension, hyperlipidemia, or diabetes. Cardio embolic strokes are associated with cardiac dysrhythmias, such as atrial fibrillation, but can also be associated with valvular heart disease or left ventricular thrombus. The last two classifications of ischemic strokes are cryptogenic strokes, which have no identified cause, and strokes from other causes, such as illicit drug use (cocaine), coagulopathies, migraine, or spontaneous dissection of the carotid or vertebral arteries.
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? Checking stools for occult blood Performing range-of-motion (ROM) exercises on the left side Keeping skin clean and dry Elevating the head of the bed to 30 degrees
Elevating the head of the bed to 30 degrees 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. Checking the stools, performing ROM exercises, and keeping the skin clean and dry are important, but preventing aspiration through positioning is the priority.
A client undergoes cerebral angiography for evaluation of a subarachnoid hemorrhage. Which findings indicate spasm or occlusion of a cerebral vessel by a clot? A. Hemiplegia, seizures, and decreased level of consciousness B. Tachycardia, tachypnea, and hypotension C. Nausea, vomiting, and profuse sweating D. Difficulty breathing or swallowing
Hemiplegia, seizures, and decreased level of consciousness Spasm or occlusion of a cerebral vessel by a clot causes signs and symptoms similar to those of a stroke: hemiplegia, seizures, decreased level of consciousness, aphasia, hemiparesis, and increased focal symptoms. Nausea, vomiting, and profuse sweating suggest a delayed reaction to the contrast medium used in cerebral angiography. Difficulty breathing or swallowing may signal a hematoma in the neck. Tachycardia, tachypnea, and hypotension suggest internal hemorrhage.
A client diagnosed with migraine headaches asks the nurse what he can do to help control the headaches and minimize the number of attacks he is having. What instructions should the nurse give this client? Identify and avoid factors that precipitate or intensify an attack. Keep a record of activities following an attack. When an attack occurs, stay in a brightly lit area. Write down any adverse drug effects.
Identify and avoid factors that precipitate or intensify an attack.
A client is receiving an IV infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To confirm that this drug is producing its therapeutic effect, the nurse should consider which finding most significant? A. Decreased heart rate B. Decreased level of consciousness (LOC) C. Elevated blood pressure D. Increased urine output
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.
Which are contraindications for the administration of tissue plasminogen activator (t-PA)? Select all that apply. Intracranial hemorrhage Ischemic stroke Age 18 years or older Systolic BP less than or equal to 185 mm Hg Major abdominal surgery within 10 days
Intracranial hemorrhage Major abdominal surgery within 10 days Intracranial hemorrhage, neoplasm, aneurysm, and major surgical procedures within 14 days are contraindications to t-PA. Clinical diagnosis of ischemic stroke, being 18 years of age or older, and a systolic BP less than or equal to 185 mm Hg are eligibility criteria.
A client has experienced an ischemic stroke that has damaged the lower motor neurons of the brain. Which of the following deficits would the nurse expect during assessment? A. Limited attention span and forgetfulness B. Visual agnosia C. Auditory agnosia D. Lack of deep tendon reflexes
Lack of DTR Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia. If damage has occurred to the frontal lobe, learning capacity, memory, or other higher cortical intellectual functions may be impaired. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and lack of motivation. Damage to the lower motor neurons may cause decreased muscle tone, flaccid muscle paralysis, and a decrease in or loss of reflexes.
A client is admitted for evaluation of cerebral aneurysm. Which assessment finding is of greatest importance in prioritizing nursing care to this client? Complaint of headache off and on for past month No bowel movement since yesterday Nausea Frequent voiding
Nausea Nausea needs to be controlled to prevent vomiting, which can greatly increase the intracranial pressure and subsequently rupture the aneurysm. Complaint of headache for past month is significant and probably attributes to the evaluation at hand. Having no bowel movement since yesterday is not significant; although, every effort should be made to prevent constipation. Frequent voiding is expected especially with the use of osmotic diuretics.
While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are: A. Confusion or change in mental status B. Severe headache and early change in level of consciousness C. Weakness on one side of the body and difficulty with speech D. Foot drop and external hip rotation
Severe headache and early change in level of consciousness The main presenting symptoms for ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body, confusion or change in mental status, and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Foot drop and external hip rotation can occur if a stroke victim is not turned or positioned correctly.
What nursing intervention is appropriate for a client with receptive aphasia? Encourage the client to repeat sounds of the alphabet. Explore the client's ability to write. Speak slowly and clearly. Frequently reorient the client to time, place, and situation.
Speak slowly and clearly.
When developing a care plan for a client who has recently suffered a stroke, a nurse includes the nursing diagnosis Risk for imbalanced body temperature. What is the rationale for this diagnosis?
The stroke may have impacted the body's thermoregulation centers
Which of the following diagnostics are beneficial to detect intracranial stenosis? Transcranial Doppler (TCD) Computed tomography (CT) CT with contrast Magnetic resonance imaging (MRI)
Transcranial Doppler (TCD) TCD useful in detecting severe intracranial stenosis, in evaluating the carotid and vertebrobasilar vessels, in assessing patterns and extent of collateral circulation in pts with known arterial stenosis or occlusion, and in detecting microemboli.
receptive aphasia
cant comprehend words being said to them nurse: speaks clear, dont hurry, have pt try and read
expressive aphasia
cant form words have pt practice ABCs have pt try and write
A client who's paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis?
the client sues a mirror to inspect the skin The client demonstrates understanding of safety measures related to paralysis when he uses a mirror to inspect his skin. The mirror enables the client to inspect all areas of the skin for signs of breakdown without the help of staff or family members. The client should keep the side rails up to help with repositioning and to prevent falls. The paralyzed client should take responsibility for repositioning or for reminding the staff to assist with it, if needed. A client with left-side paralysis may not realize that the left arm is hanging over the side of the wheelchair. However, the nurse should call this position to the client's attention because the arm can get caught in the wheel spokes or develop impaired circulation from being in a dependent position for too long.
