Stroke

Which response would the nurse include when a patient's caregiver asks how to care for a patient who is being discharged home after treatment for a hemorrhagic stroke? Select all that apply. "Be sure to keep scheduled appointments every week." "Assist with range-of-motion (ROM) activities to prevent atrophy." "Ensure that the patient feeds themself every time without assistance." "Ensure that the patient takes antihypertensive medication every day at the evening meal." "If you notice any worsening of symptoms, you should contact the health care provider immediately."

"Be sure to keep scheduled appointments every week." "Assist with range-of-motion (ROM) activities to prevent atrophy." "Ensure that the patient takes antihypertensive medication every day at the evening meal." "If you notice any worsening of symptoms, you should contact the health care provider immediately."

Which statement from the nurse to a patient with known risk factors for stroke would indicate the need for more education on stroke prevention? "Reduce salt and sodium intake." "Limit alcohol use to moderate levels." "Follow a diet high in saturated fat." "Engage in moderate exercise for 150 minutes per week."

"Follow a diet high in saturated fat."

Which response would the nurse provide when a patient who is scheduled to undergo a Guglielmi detachable coils procedure asks why this procedure is being done? "It prevents blood from entering the aneurysm." "It promotes anticoagulation so the blood flows freely." "It reduces the exchange of calcium ions to prevent vasospasm." "It can protect against an aneurysm rupture by encouraging clot formation."

"It can protect against an aneurysm rupture by encouraging clot formation."

Which statement from the nurse regarding the action they will take after a stenting procedure indicates the need for further education? "Check the patient's blood pressure." "Perform a neurovascular assessment on the patient." "Ensure there is no stent occlusion." "Keep the patient's leg bent."

"Keep the patient's leg bent."

Which type of airway would the nurse anticipate for a comatose stroke patient to prevent the tongue from obstructing the airway? Endotracheal intubation Nasopharyngeal airway Oropharyngeal airway Tracheostomy

Oropharyngeal airway

Which statistic accurately explains why stroke is a major public health concern? 20% of strokes occur in people younger than 65 years old. 230,000 deaths occur each year from stroke. Stroke is the second most common cause of death in the United States. Seven million adults in the United States have had a stroke.

Seven million adults in the United States have had a stroke.

Which time interval is an accurate goal for the door-to-stroke team for a patient with ischemic stroke? ≤10 min ≤15 min ≤25 min ≤45 min

≤15 min

In which artery would the nurse expect a patient's stroke to have occurred if the patient experiences loss of proprioception and fine touch? Anterior cerebral Middle cerebral Vertebral Posterior cerebral

Anterior cerebral

Which therapy would the nurse expect to be ordered to reduce the risk for stroke in a patient who has atrial fibrillation? Antihypertensive O2 Constraint-induced movement Anticoagulant

Anticoagulant

Which therapy would the nurse prepare a patient for after the patient has suffered an acute stroke and is determined to not be a candidate for surgical therapy? Anticoagulation Carotid endarterectomy Fluid therapy Transluminal angioplasty

Anticoagulation

Which diagnostic test would the nurse immediately prepare the patient for who arrives at the emergency department with symptoms of a stroke? Cardiac marker levels Complete blood count (CBC) Computed tomography (CT) scan Transcranial doppler (TCD) ultrasonography

Computed tomography (CT) scan

Which function would the nurse discuss when the family asks why the occupational therapist is involved in the care of a patient with acute stroke? Evaluating ability to perform self-care Assessing musculoskeletal function Recommending functional position Assessing swallowing reflex

Evaluating ability to perform self-care

Which suggestion would the nurse provide a patient who is being treated for an ischemic stroke and asks the nurse if there is any way to prevent complications of a stroke without drug therapy? Increase fiber in their diet. Limit water intake. Restrict movement. Recommend an indwelling catheter to prevent incontinence.

Increase fiber in their diet.

Which rehabilitation order would the nurse expect for a patient who has had a hemorrhagic stroke and was recently evaluated for dysphagia by a speech therapist? Initiate oral diet. Teach the patient to use the affected extremity to eat. Provide a nutritional supplement to correct nutritional deficits. Initiate oral feeding with the head of the bed elevated to 30 degrees.

Initiate oral diet.

Which intervention is most effective for preventing venous thromboembolism (VTE) in a stroke patient? Keep the patient moving. Position to minimize the effects of dependent edema. Use intermittent pneumatic compression devices. Administer low-molecular-weight heparin.

Keep the patient moving.

Which procedure would the nurse expect to prepare a patient for when the patient is suspected of having a hemorrhagic stroke but magnetic resonance imaging (MRI) is inconclusive? Coiling Blood draw Radiosurgery Lumbar puncture

Lumbar puncture

Which diagnostic test would the nurse expect to be performed if a patient is suspected to have an embolic stroke and the interprofessional team needs to determine if red blood cells are present in the cerebrospinal fluid (CSF)? Angiography Digital subtraction angiography (DSA) Transcranial doppler (TCD) ultrasonography Lumbar puncture (LP)

Lumbar puncture (LP)

Which goal would the nurse include when caring for a patient who has had a stroke? Minimize physical function. Maintain adequate nutrition. Minimize self-care abilities. Attain minimum communication abilities.

Maintain adequate nutrition

Which information is collected as part of the health perception-health management assessment of a patient who has had a stroke? Neurologic disorders Alcohol use Loss of movement Change in bowel patterns

Alcohol use

Total scores on the NIH Stroke Scale (NIHSS) range from ________ , with higher values reflecting more severity.

0-42

At which time frame after stabilization has been reached would the nurse shift care goals to rehabilitation for a stroke patient? 8 hours 48 hours 6 hours 15 hours

15 hours After the stroke patient has stabilized for 12 to 24 hours, care goals shift from preserving life to lessening disability and reaching optimal function.

At a dose _______ of mg/day, aspirin is the most often used antiplatelet agent

81

Which factor is used to help determine the discharge planning for a patient who has had a stroke? Willingness to quit smoking Ability to manage medications independently Ability to perform activities of daily living (ADLs) Scheduling an initial appointment with a career counselor

Ability to perform activities of daily living (ADLs)

Which condition would the nurse expect of a patient who is unable to recognize an object by sight, touch, or hearing? Apraxia Agnosia Incorrect perception of self Spatial neglect

Agnosia

Which nursing action is a priority for a patient who has experienced an ischemic stroke and is depressed and having trouble coping? Ask the patient how they feel about the diagnosis. Describe to the patient the experiences of other patients who you have treated for stroke. Ask the patient to move to an empty room if an emotional outburst is upsetting others. Explain to the patient that an unusual emotional reaction to the diagnosis may indicate an altered level of consciousness and increased intracranial pressure (ICP).

Ask the patient how they feel about the diagnosis.

Which nursing assessment is a priority for a patient who has suffered an ischemic stroke, has been admitted to the hospital, and is in stable condition after tissue plasminogen activator (tPA) treatment? Obtaining a patent airway Drawing blood for cardiac markers Asking the patient to touch the nose Asking the patient simple time and place questions

Asking the patient simple time and place questions

Which action by the new nurse when caring for a patient scheduled to start oral feedings after an ischemic stroke would require an intervention by the nurse preceptor? Give the patient 1 ounce of water to swallow. Tell the patient to sit up before swallowing. Assist the patient to sit in a chair before feeding the patient. Assess cranial nerves III, IV, and VI before attempting feeding.

Assess cranial nerves III, IV, and VI before attempting feeding.

Which function is the nurse's primary role during tissue plasminogen activator (tPA) administration for a patient who is diagnosed with acute onset of ischemic stroke? Insert a urinary catheter. Administer anticoagulant. Assess patient's level of consciousness. Prepare patient for a magnetic resonance imaging (MRI).

Assess patient's level of consciousness.

Which patient care goal would the nurse include before discharge of a patient who is being treated for a hemorrhagic stroke, is alert and able to verbalize basic needs and wants, and is able to use the bathroom with assistance but continues to have facial paralysis? Maintain stable body functions. Assess the patient for dysphagia. Discuss physical therapy options. Improve communication abilities.

Assess the patient for dysphagia.

Which data collected from a patient who has had a stroke would be included in the objective assessment? Family history Medications Cardiovascular Elimination

Cardiovascular

Which treatment would the nurse describe to a patient with a history of a brain aneurysm, who is in the clinic for a routine examination and wants to know if there are any ways to prevent complications of the aneurysm? Clipping Nimodipine Radiosurgery Hyperdynamic therapy

Clipping

Which intervention would the nurse use for a stroke patient who has increased intracranial pressure (ICP)? Administer antihypertensives. Elevate the head of the bed. Maintain glycemic control. Monitor urine output.

Elevate the head of the bed.

Which type of stroke would the nurse explain that a patient has, when the patient is being evaluated for an ischemic stroke and tells the nurse that the primary health care provider indicated that a narrowing of blood vessels caused the stroke? Embolic Thrombotic Intracerebral Subarachnoid

Embolic

Which purpose does interventional neuroradiology serve for a patient who arrives in the emergency department with signs of a hemorrhagic stroke, whose electronic health record indicates a history of arteriovenous malformation (AVM), and who is scheduled for a gamma knife procedure and interventional neuroradiology? Placing a clip Embolizing the blood vessels Preventing further stroke symptoms Preventing the aneurysm from rebleeding

Embolizing the blood vessels

Which reason indicates why the Bobath method is used for rehabilitation of a patient who has had a stroke? Encourages the patient to use the weakened extremity by restricting movement of the unaffected extremity Assesses whether patients autocorrect their posture when sitting on the edge of the bed Guides the patient into a sitting position Helps the patient gain control over spasticity by inhibiting abnormal reflex patterns

Helps the patient gain control over spasticity by inhibiting abnormal reflex patterns

Which procedure would be performed on a patient who has had an aneurysm clipped, to increase the mean arterial pressure? Surgical resection Catheter embolization Flow diversion Hyperdynamic therapy

Hyperdynamic therapy

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

Hypertension

Which nursing intervention is a priority to ensure that a patient who has become immobilized after suffering a stroke is being discharged from the hospital receives appropriate posthospital care? Advise the patient to join a support group. Identify appropriate rehabilitation resources. Instruct patient in use of an oropharyngeal airway. Teach the patient to administer parenteral nutritional support.

Identify appropriate rehabilitation resources.

Which assessment finding would the nurse expect in a patient admitted with a right-brain stroke? Paralyzed right side Impaired right/left discrimination Impaired judgment Slow performance

Impaired judgment

Which teaching, regarding minimizing the risk of stroke, would the nurse provide for a patient who is concerned about the risk of ischemic stroke due to a medical history of diabetes and hypertension and a family history of the condition? Select all that apply. One, some, or all responses may be correct. Avoid pregnancy. Maintain blood glucose. Start an exercise regimen. Cease chemotherapy treatment. Remain on antihypertensive medication.

Maintain blood glucose. Start an exercise regimen. Remain on antihypertensive medication.

Which nursing action would the nurse perform to prevent further brain injury in a patient who is being treated for an ischemic stroke, is under observation, and approximately 3 days after the stroke occurred, the patient is nauseous, appears confused and agitated, and has elevated blood pressure and body temperature? Have the patient lie down. Help the patient raise their legs. Maintain head and neck alignment. Offer patient extra blankets to excrete extra fluid via sweat.

Maintain head and neck alignment.

Which drug therapy for hemorrhagic strokes is patient-specific? Seizure prophylaxis Anticoagulants Platelet inhibitors Antihypertensives

Seizure prophylaxis

Which emergent order would the nurse prepare a patient for when the patient presents to the emergency room with facial drooping, slurred speech, and left-sided paralysis that began 2 hours ago? Administration of ticlopidine (Ticlid) Performance of a computerized topography (CT) scan Administration of recombinant tissue plasminogen activator (tPA) Insertion of an intracranial pressure (ICP) monitor

Performance of a computerized topography (CT) scan

Which acute care intervention would the nurse include in the care of a patient who has dysphagia following an ischemic stroke? Offer thin liquids with meals. Use straws with liquids. Restrict oral and parenteral nutrition. Place the patient on aspiration precautions.

Place the patient on aspiration precautions.

Which medication order would the nurse question for a patient with hypertension who is diagnosed with a hemorrhagic stroke resulting from intracranial hemorrhage, whose symptoms began several hours earlier and have been progressively worsening? β-Blockers Platelet inhibitor Antiseizure medication Calcium channel blocker

Platelet inhibitor

Which health promotion measure is recommended to help prevent stroke? Switch to a high-fat diet. Maintain a systolic BP less than 160 mm Hg. Engage in moderate exercise 100 minutes per week. Reduce sodium intake.

Reduce sodium intake.

Which factor would have the most impact on coping when the nurse is planning psychosocial support for the family of a patient who had a stroke? Specific patient neurologic deficits Patient's ability to communicate Rehabilitation potential of the patient Presence of complications of a stroke

Rehabilitation potential of the patient

Which preventive measure would the nurse and health care team suggest for a patient being treated for a transient ischemic attack (TIA) to help prevent an embolic stroke? Select all that apply. One, some, or all responses may be correct. Take aspirin 81 mg/day. Eat a well-balanced diet. Limit alcohol consumption. Adopt a moderate exercise regimen. Administer recombinant tissue plasminogen activator (tPA).

Take aspirin 81 mg/day. Eat a well-balanced diet. Limit alcohol consumption. Adopt a moderate exercise regimen

Which action would be the highest priority for the nurse before administration of nimodipine to a patient at high risk for a hemorrhagic stroke who has just had a clipping procedure to treat an aneurysm? Take the patient's vital signs. Administer an anticonvulsant. Evaluate the size of the hematoma. Educate the patient about maintaining a healthy lifestyle.

Take the patient's vital signs.

Which topic would the nurse focus on when stroke (STK) core measure 4 is discussed with a patient? Venous thromboembolism (VTE) prophylaxis Discharge on statin medication Discharge on antithrombotic therapy Thrombolytic therapy

Thrombolytic therapy

Which teaching would be provided for a patient who has had a stroke and is concerned about the loss of sexual function? Timing for peak energy periods Communication techniques Range-of-motion (ROM) exercises Swallowing techniques

Timing for peak energy periods