Stroke (EAQ)
"The pt should be placed in a supine position" Rationale: If the nurse suspects increased intercranial pressure, the patient's head should be elevated and the head and neck should be aligned to improve venous drainage. Constipation increases intracranial pressure; therefore, treating constipation is important. The patient's body temperature should be maintained at or near normal (96.8° F to 98.6° F) to avoid hyperthermia. Text Reference - p. 1398
A registered nurse is teaching a student nurse about the management of increased intracranial pressure in a patient who sustained a stroke. Which statement made by the student nurse indicates the need for further teaching? A. "The patient should be placed in a supine position." B. "The patient's head and neck should be in alignment." C. "The patient's bowel function status should be maintained." D. "The patient's temperature should be maintained between 96.8° F to 98.6° F
tPA should be administered within 12 hours of the onset of a stroke Rationale: When tPA is administered to patients with an acute onset of ischemic stroke, it is administered intravenously (IV) and should be provided 3 to 4.5 hours from the onset of a stroke, not 12 hours. When administered by intraarterial infusion, tPA is delivered directly to the clot and can be administered up to 6 hours after the onset of stroke symptoms. It is important to monitor blood pressure during the treatment and for 24 hours after the fibrinolytic treatment. If blood pressure is not controlled, it can alter the fibrinolytic treatment. Text Reference - p. 1398
A registered nurse is teaching a student nurse about tissue plasminogen activator (tPA) administration in a patient with ischemic stroke. Which statement made by the student nurse indicates a need for further teaching? A. tPA is administered intravenously (IV) B. tPA is administered by intraarterial infusion C. tPA should be administered within 12 hours of the onset of a stroke D. tPA requires blood pressure monitoring during and 24 hours after the treatment
Measuring urine output Rationale: Measuring the urine output is within the scope of practice of unlicensed assistive personnel (UAP). However, it is not within the UAP's scope of practice to assess the patient. Assessment of respiratory status and swallowing ability and monitoring cardiovascular status are only performed by the registered nurse. Text Reference - p. 1405
The nurse is developing a plan of care for a patient with an acute ischemic stroke in the first 48 hours after admission. What activity can the nurse delegate to the unlicensed assistive personnel (UAP)? A. Measuring urine output B. Assessing the respiratory status C. Assessing the swallowing ability D. Monitoring the cardiovascular status
B, D, E Rationale: The nurse should check the mouth for pocketing of food after eating to prevent collection and putrefaction of food and/or aspiration. The nurse should help the patient to maintain a sitting position for 30 minutes after completing a meal to prevent regurgitation of food. Placing food on the unaffected side of the mouth prevents it from collecting on the affected side. The patient should be made to sit in an erect position to provide an optimal position for chewing and swallowing without aspiration. The nurse should help the patient to position the head in forward flexion in preparation for swallowing.
A nurse is caring for a patient who is not able to swallow properly post stroke. What interventions are important to facilitate patient safety during eating? Select all that apply. A. Place patient in a low Fowler's position. B. Check mouth for pocketing of food. C. Help the patient to position the head in backward extension to promote swallowing. D. Help the patient maintain a sitting position for 30 minutes after a completing meal. E. Place food on the unaffected side of the mouth.
A, B, C Rationale: In ischemic stroke, recombinant tPA is used to produce localized fibrinolysis by binding to the fibrin thrombi. Patients are screened before tPA can be given. Screening includes a noncontrast CT or magnetic resonance imaging to rule out hemorrhagic stroke; a blood test for glucose level and coagulation disorders; and screening for recent history of gastrointestinal bleeding, stroke or head trauma within the past three months, or major surgery within 14 days. The patient who underwent major surgery two years ago can be given tPA, because there is no risk of bleeding. The patient with a blood sugar level of 110 mg/dL can be administered tPA safely, because the blood sugar level is normal. The patient with a history of head injury six months previously can also be administered tPA, because there is no risk of bleeding. However, the patient with a CT scan showing hemorrhagic stroke or the patient with hemophilia have a very high risk of bleeding due to the fibrinolytic action of tPA; therefore, it should not be administered to these patients. Text Reference - p. 1398
A nurse is screening patients to determine if administering tissue plasminogen activator (tPA) for fibrinolytic therapy is an appropriate intervention. Which patients may be administered tPA safely? Select all that apply. A. A 25-year-old with history of cholecystectomy two years previously B. A 70-year-old with blood sugar levels of 110 mg/dL C. A 40-year-old with history of head injury six months ago D. A 35-year-old with a computed tomography (CT) scan showing hemorrhagic stroke E. A 30-year-old with hemophilia A
"When did the facial drooping begin?" Rationale: The time of onset of symptoms determines which treatments can be given and is the most critical information the nurse should obtain in the history assessment. The family history, past incidence, and pain are all important but do not impact treatment to the same extent as time of symptom onset.
A patient is admitted to the emergency department with right-sided facial drooping. When taking the patient's history, which information would be most significant? A. "When did the facial drooping begin?" B. "Do you have a family history of stroke?" C. "Have you had facial drooping in the past?" D. "Are you having any pain on the right side of your face?"
Carotid endarterectomy Rationale: A carotid endarterectomy is depicted in the image. This procedure removes plaque from the inner lining of the carotid artery and helps maintain blood flow. Stenting, transluminal angioplasty, and extracranial-intracranial bypass also help maintain blood flow, but are not shown in the figure. In stenting, stents are used to open the narrow arteries to maintain proper blood flow. Transluminal angioplasty opens narrow arteries with a catheter to maintain proper blood flow. In extracranial-intracranial bypass, a branch of the external carotid artery is connected to a branch of the internal carotid artery. It removes the blockage created in the artery and helps maintain blood flow. Text Reference - p. 1397
A patient is diagnosed with a transient ischemic attack due to carotid artery disease. Which surgical procedure would the primary health care provider suggest for this patient, as depicted in the image? A. Stenting B. Carotid endarterectomy C. Transluminal angioplasty D. Extracranial-intracranial bypass
A, D Rationale: If a patient stops smoking, his or her risk of a stroke dramatically decreases over time. Although hypertension is the most important modifiable stroke risk factor, it often is not diagnosed and not treated. Atrial fibrillation increases the risk of a thrombotic stroke, not hemorrhagic stroke. HDL is the good type of cholesterol. Elevated low-density lipoproteins (LDL) increase the risk for a stroke. If a patient experiences any sign or symptom of a stroke, including muscle weakness, he or she should call 911 instead of calling for an appointment with the primary health care provider. Text Reference - p. 1401
A patient who had a transient ischemic attack (TIA) is being discharged home from the hospital. Before discharge, the patient should be taught that: Select all that apply. A. Smoking cessation decreases risk of a stroke. B. Atrial fibrillation increases the risk of hemorrhagic stroke. C. Elevated high-density lipoprotein (HDL) increases risk of stroke. D. Hypertension is the most important modifiable stroke risk factor. E. If experiencing sudden muscle weakness, immediately schedule an appointment with the primary health care provider.
Checking for stool impaction Rationale: Stool impaction is the development of a solid immobile mass of fecal matter in the rectum, which may result in liquid stool. Therefore, the nurse should assess for this first. An enema helps facilitate bowel movements, but should be avoided because it increases the intracranial pressure. Psyllium is a form of fiber used to increase the solid mass in the intestine so the feces can pass easily. Physical activity stimulates bowel function, so the nurse should encourage the patient to perform physical activity. Text Reference - p. 1405
A patient who sustained a hemorrhagic stroke and has increased intracranial pressure reports to the nurse about loose stools. What is the priority nursing action? A. Administering enemas B. Administering psyllium C. Checking for stool impaction D. Discouraging physical activity
B, D Rationale: Oral contraceptive pills with high levels of progestin and estrogen increase a woman's chance of experiencing stroke. People with migraine are at an increased risk of stroke, although the mechanism for the increased risk in young women with migraine remains unknown. Low back pain, hair loss, and past employment with dyes do not increase the risk of stroke. Test-Taking Tip: Survey the test before you start answering the questions. Plan how to complete the exam in the time allowed. Read the directions carefully and answer the questions you know for sure first. Text Reference - p. 1389
During assessment of a female patient who has experienced a stroke, the nurse notes certain findings. What are the findings that could be associated with the stroke? Select all that apply. A. The patient has low back pain. B. The patient is on oral contraceptives. C. The patient has long-standing hair loss. D. The patient has a history of migraine with aura. E. The patient had past employment involving work with dyes.
Maintaining NPO status Rationale: During the acute phase of stroke management, it is important for patients to be kept NPO until dysphagia has been ruled out. The presence of an oral-pharyngeal airway will aid in maintaining patency of airway and does not minimize the risk of aspiration. Elevating the head of the bed does decrease the risk of aspiration, but it is more important to eliminate oral intake until swallowing is evaluated. Placing suction equipment at the bedside is important for the management, not prevention, of aspiration.
During the acute phase of stroke management, the most important nursing intervention to decrease risk of aspiration is: A. Maintaining nothing by mouth (NPO) status. B. Placing an oral-pharyngeal airway. C. Elevating head of bed 30 degrees. D. Placing suction equipment at the bedside.
Ask simple yes/no questions Rationale:Asking questions that can be answered simply supports communication in the acute phase of a stroke. Verbal communication should not be limited but should be frequent and meaningful. Diverting eye contact is incorrect because it will increase embarrassment instead of reducing it. It is important to give the patient time to answer a question. Asking a second question before the patient has had time to answer the first one will increase frustration and decrease communication.
During the acute stage of a stroke, it is important for the nurse to include which intervention for a patient experiencing aphasia? A. Ask simple yes and no questions B. Limit verbal communication to reduce frustration C. If the patient is unable to answer a question, divert eye contact to reduce embarrassment D. If patient does not answer immediately, ask the patient if he or she understands or needs you to repeat the information
"I need to keep in close contact with my health care provider because I need frequent blood tests to adjust the medication dose." Rationale: The drug clopidogrel often is prescribed after a TIA to prevent strokes. Clopidogrel is an antiplatelet aggregator aimed at preventing clot formation. This medication does not require frequent blood tests for dose adjustments like warfarin. It is important that the patient inform other health care providers and dentists about taking this medication, because the medication is often stopped 10 to 14 days before surgery or dental procedures. Because many herbal products interfere with prescription medications, it is important for the patient to discuss any herbal, alternative, or over-the-counter medication use with the health care provider. Because clopidogrel prevents platelets from aggregating, the patient will experience prolonged bleeding; therefore, the patient should take extra precautions to avoid injuries or cuts. Text Reference - p. 1396
The nurse is providing education on the drug clopidogrel for a patient who experienced a transient ischemic attack (TIA). Which patient statement indicates a need for further teaching? A. "I will let my dentist know that I started this medication." B. "I need to check with my health care provider before taking any of my herbal supplements." C. "I need to be careful to avoid cutting myself when working with sharp garden tools." D. "I need to keep in close contact with my health care provider because I need frequent blood tests to adjust the medication dose."
Warning of impending stroke Rationale: Transient ischemic attacks (TIAs) can be a warning of an impending stroke or cerebrovascular accident. They may occur hours or days before. TIAs are usually not neurologically damaging or a sign of progressive brain damage. Patients should be instructed to report TIAs to the health care provider and not ignore them.
The nurse provides care for a patient who has had a transient ischemic attack (TIA). The patient's spouse asks about the significance of the condition. How should the nurse explain a TIA? A. It is usually neurologically damaging. B. It is a signal of progressive brain damage. C. It can be a warning of an impending stroke. D. It is nothing to be concerned about because it is not a stroke.
Perform passive ROM to flaccid extremities Rationale: After appropriate training and evaluation, the UAP can perform passive range of motion exercises to patients who have had a stroke. Assessment of airway, gag reflex, and level of orientation requires more advanced skills and evaluation than is in the scope of practice of the UAP.
The nurse uses appropriate delegation of assignments when instructing the experienced unlicensed assistive personnel (UAP) to: A. Suction oral pharynx as needed B. Assess orientation every four hours C. Perform passive range of motion to flaccid extremities D. Assure gag reflex is intact before offering fluids or food
Impaired speech 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. Test-Taking Tip: Bring to your test prep a positive attitude about yourself, your nursing knowledge, and your test-taking abilities. A positive attitude is achieved through self-confidence gained by effective study. This means (a) answering questions (assessment), (b) organizing study time (planning), (c) reading and further study (implementation), and (d) answering questions (evaluation). Text Reference - p. 1393
The nurse would expect to find what clinical manifestation in a patient admitted with a left-hemispheric stroke? A. Impulsivity B. Impaired speech C. Left-side neglect D. Short attention span
Safety measures Rationale: A patient with a right-hemispheric stroke has spacial-perceptual deficits, tends to minimize problems, has a short attention span, is impulsive, and may have impaired judgment. Safety is the biggest concern for this patient. Hemiplegia occurs on the left side of this patient's body. The patient with a left-hemispheric stroke has hemiplegia on the right, is more likely to have communication problems, and needs mobility assistance on the right side, with food placed on the left side if the patient needs to be fed after a swallow evaluation has taken place.
The patient with diabetes mellitus has had a right-hemispheric stroke. Which nursing intervention should the nurse plan to provide for this patient related to expected manifestations of this stroke? A.Safety measures B. Patience with communication C. Mobility assistance on the right side D. Placing food in the left side of the patient's mouth
A, B Rationale: A person in a Fowler's position is sitting straight up or leaning slightly back. The legs may either be straight or bent. A high Fowler's position is sitting upright. This helps in feeding, as well as swallowing, for the patient. Sitting in a chair with the head flexed forward also serves a similar purpose. Low Fowler's, Trendelenburg's, and right lateral positions are not appropriate for feeding. Text Reference - p. 1406
What precautions should the nurse follow when feeding a patient with a stroke on the left side? Select all that apply. A. Place the patient in high Fowler's position. B. Place the patient in a chair with the head flexed forward. C. Place the patient in low Fowler's position. D. Place the patient in Trendelenburg's position. E. Place the patient in right lateral position.
Slow and possibly fearful performance of tasks. Rationale: Patients with a left-hemispheric stroke (right hemiplegia) commonly are slower in organization and performance of tasks and may have a fearful, anxious response to a stroke. Overconfidence, spatial disorientation, and impulsivity more commonly are associated with a right-hemispheric stroke.
Which sensory-perceptual deficit is associated with left-hemispheric stroke (right hemiplegia)? A. Overestimation of physical abilities B. Difficulty judging position and distance C. Slow and possibly fearful performance of tasks D. Impulsivity and impatience at performing tasks