ch 57 Stroke
left homonymous hemianopsia
right sided brain damage
loss of depth perception: left or right sided brain damage?
right sided brain damage
poor impulse control and judgment: left or right sided brain damage?
right sided brain damage
short attention span: left or right sided brain damage?
right sided brain damage
unilateral neglect syndrome: left or right sided brain damage?
right sided brain damage (ignore left side of the body: cannot see, feel, or move affected side, so client unaware of its existence)
stroke risk factors: nonmodifiable (4)
-age -gender (more common in men) -ethnicity (more common in African Americans) -family history
feeding a pt with dysphagia
-assess swallowing and gag reflex before feeding -have client eat in an upright position and swallow with the head and neck flexed slightly forward -place food in the back of the mouth on the unaffected side -have suction on standby -provide a distraction-free environment during meals
nursing interventions acute stroke: management of intracranial pressure (4)
-elevate HOB to at least 30 degrees -maintain head and neck alignment -monitor pt's temp (fever can cause increased ICP) -monitor LOC (decreased LOC = increased ICP)
nursing interventions acute stroke: respiratory (6)
-frequent assessment of airway -provide oxygenation -suctioning -promoting pt mobility -positioning pt to prevent aspiration -encouraging deep breathing
important medical hx to obtain
-hx of similar symptoms previously experienced (ex: TIA) -hx of risk factors and other illnesses (ex: hypertension) -family hx of stroke, aneurysm, or cardiovascular disease
stroke risk factors: modifiable (9)
-hypertension -smoking -hyperlipidemia -diabetes mellitus -heart disease -use of oral contraceptives -obesity, physical inactivity -sleep apnea -drug and alcohol abuse
drug therapy for hemorrhagic stroke
-main drug therapy for pts with hemorrhagic stroke is the management of hypertension -no blood thinners
VTE assessment (4)
-measuring calf and thigh daily -observing for swelling of lower extremities -noting unusual warmth of the leg -asking pt about pain in the calf
nursing interventions acute stroke: cardiovascular (5)
-monitor BP (HTN is sometimes seen after a stroke) -VTE prophylaxis -monitoring cardiac rhythms -calculating intake and output -monitoring lung sounds (crackles and wheezes indicate pulmonary congestion)
interventions for aphasia (5)
-provide repetitive directions -break tasks down to 1 step at a time -repeat names of objects frequently -allow time for the client to communicate -use a picture board, communication board, or computer technology (NCLEX)
thrombotic vs embolic stroke: onset
-thrombotic: often occurs during sleep, TIA is a warning -embolic: sudden onset
how to assess swallowing ability
1. elevate the head of the bed to an upright position 2. give the pt a very small amount (less than 8 oz) of crushed ice or ice water to swallow
The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke. Which characteristics are associated with this condition? (Select all that apply) 1. the client is aphasic 2. the client has weakness on the right side of the body 3. the client has complete bilateral paralysis of the arms and legs 4. the client has weakness on the right side of the face and tongue 5. the client has lost the ability to move the right arm but is able to walk independently 6. the client has lost the ability to ambulate independently but is able to feed and bathe himself or herself without assistance
1. the client is aphasic 2. the client has weakness on the right side of the body 4. the client has weakness on the right side of the face and tongue NCLEX
The nurse has instructed the family of a client with stroke who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? 1. "We need to discourage him from wearing eyeglasses." 2. "We need to place objects in his impaired field of vision." 3. "We need to approach him from the impaired field of vision." 4. "We need to remind him to turn his head to scan the lost visual field."
4. "We need to remind him to turn his head to scan the lost visual field." NCLEX
The nurse is caring for a client who has just been admitted to the hospital with a diagnosis of a hemorrhagic stroke. The nurse should plan to place the client in which position? 1. Prone 2. Supine 3. Semi-Fowler's with the hip and the neck flexed 4. Head of the bed elevated 30 degrees with the head in midline position
4. Head of the bed elevated 30 degrees with the head in midline position
The nurse is assessing the adaption of a client to changes in functional status after a stroke. Which observation indicates to the nurse that the client is adapting most successfully? 1. gets angry with family if they interrupt a task 2. experiences bouts of depression and irritability 3. has difficulty with using modified feeding utensils 4. consistently uses adaptive equipment in dressing self
4. consistently uses adaptive equipment in dressing self NCLEX
The nurse is discharging a patient admitted with a transient ischemic attack (TIA). For which medications might the nurse expect to provide discharge instructions (select all that apply)? A. Clopidogrel (Plavix) B. Enoxaparin (Lovenox) C. Dipyridamole (Persantine) D. Enteric-coated aspirin (Ecotrin) E. Tissue plasminogen activator (tPA)
A. Clopidogrel (Plavix) C. Dipyridamole (Persantine) D. Enteric-coated aspirin (Ecotrin)
A nurse is planning care for a client who has dysphagia and has a new dietary prescription. Which of the following should the nurse include in the plan of care? (Select all that apply) A. Have suction equipment available for use B. Use thickened liquids C. Place food on the client's unaffected side of her mouth D. Assign as assistive personnel to feed the client slowly E. Teach the client to swallow with her neck flexed
A. Have suction equipment available for use B. Use thickened liquids C. Place food on the client's unaffected side of her mouth E. Teach the client to swallow with her neck flexed ATI
Computed tomography (CT) of a 68-year-old male patient's head reveals that he has experienced a hemorrhagic stroke. What is the priority nursing intervention in the emergency department? A. Maintenance of patient's airway. B. Positioning to promote cerebral perfusion. C. Control of fluid and electrolyte imbalances. D. Administration of tissue plasminogen activator (tPA)
A. Maintenance of patient's airway.
A nurse is caring for a client who has global aphasia (both receptive and expressive). Which of the following should the nurse include in the client's plan of care? (Select all that apply) A. Speak to the client at a slower rate B. Assist the client to use flash cards with pictures C. Speak to the client in a loud voice D. Complete sentences that the client cannot finish E. Give instructions one step at a time
A. Speak to the client at a slower rate B. Assist the client to use flash cards with pictures E. Give instructions one step at a time ATI
A patient whose speech is slurred and difficult to understand is experiencing: A. aphasia. B. dysarthria. C. dysphagia. D. paraplegia.
B. dysarthria EMT book
A 63-year-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? a. Obtain computed tomography (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.
C, D, A, B -oxygen -stroke scale -CT scan -tPA
A patient with a history of rheumatic heart disease arrives in the emergency room 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." What condition should the nurse suspect?
Embolic stroke (embolic = sudden onset)
A patient who sustained a stroke is having a severe headache, vomiting, dysphagia, dysarthria, and eye movement disturbances. What type of stroke does the nurse determine to correlate with these clinical manifestations?
Intracerebral hemorrhage
The nurse assesses a stiff neck and cranial nerve deficits in a patient with head trauma. What does the nurse suspect has occurred with this patient?
Subarachnoid hemorrhage
dysarthria
a disturbance in the muscular control of speech
The incidence of ischemic stroke in patients with TIAs and other risk factors is reduced with administration of a. furosemide (Lasix) b. lovastatin (Mevacor) c. daily low dose aspirin d. nimodipine (Nimotop)
c. daily low dose aspirin workbook
After receiving change-of-shift report on the following four patients, which patient should the nurse see first? a. A 60-year-old patient with right-sided weakness who has an infusion of tPA prescribed b. A 50-year-old patient who has atrial fibrillation and a new order for warfarin (Coumadin) c. A 40-year-old patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due d. A 30-year-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine (Nimotop) scheduled
a. A 60-year-old patient with right-sided weakness who has an infusion of tPA prescribed (tPA needs to be infused within the first few hours after stroke symptoms start in order 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.)
A patient is admitted to the hospital with a left hemiplegia. To determine the size and location and to ascertain whether a stroke is ischemic or hemorrhagic, the nurse anticipates that the health care provider will request a a. CT scan b. lumbar puncture c. cerebral arteriogram d. positron emission tomography (PET)
a. CT scan (most commonly used diagnostic test to determine the size and location of the lesion and to differentiate a thrombotic stroke from a hemorrhagic stroke) workbook
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
a. Hypertension MS ch 57
The nurse is caring for a patient with dysphagia and is feeding her a pureed chicken diet when she begins to choke. What is the priority nursing intervention? a. Suction her mouth and throat b. Turn her on their side c. Put on oxygen at 2-L nasal cannula d. Stop feeding her and place on NPO
a. Suction her mouth and throat Fundamentals ch 45
What is an appropriate nursing intervention to promote communication during rehabilitation of the pt with aphasia? a. allow time for the individual to complete his/her thoughts b. use gestures, pictures, and music to stimulate pt responses c. structure statements so that the pt does not have to respond verbally d. use flashcards with simple words and pictures to promote recall of language
a. allow time for the individual to complete his/her thoughts workbook
What are characteristics of a stroke caused by an intracerebral hemorrhage? (Select all that apply) a. carries a poor prognosis b. caused by rupture of a vessel c. strong associated with hypertension d. commonly occurs during or after sleep e. creates a mass that compresses the brain
a. carries a poor prognosis b. caused by rupture of a vessel c. strong associated with hypertension e. creates a mass that compresses the brain workbook
Four days following a stroke, a pt is to start oral fluids and feedings. Before feeding the pt, what should the nurse do first? a. check the pt's gag reflex b. order a soft diet for the pt c. raise the HOB to a sitting position d. evaluate the pt's ability to swallow small amounts of crushed ice or ice water
a. check the pt's gag reflex -usually the speech therapist will have completed a swallowing study before a diet is ordered -the first step in providing oral feeding is ensure the pt has an intact gag reflex -after placing the pt in an upright position, the nurse may then evaluate the pt's ability to swallow ice chips or water workbook
Which type of stroke is associated with endocardial disorders, has a rapid onset, and is likely to occur during activity? a. embolic b. thrombotic c. intracerebral hemorrhage d. subarachnoid hemorrhage
a. embolic workbook
During the secondary assessment of a pt with a stroke, what should be included? (Select all that apply) a. gaze b. sensation c. facial palsy d. proprioception e. current medications f. distal motor function
a. gaze b. sensation c. facial palsy d. proprioception f. distal motor function (current medications are part of the primary assessment) workbook
During the acute phase of a stroke, the nurse assesses the patient's vital signs and neurologic status every 4 hours. A cardiovascular sign that the nurse would see as the body attempts to increase cerebral blood flow is a. hypertension b. fluid overload c. cardiac dysrhythmias d. S3 and S4 heart sounds
a. hypertension workbook
A nurse is caring for a client who has experienced a right-hemispheric stroke. Which of the following are expected findings? Select all that apply: a. impulse control difficulty b. left hemiplegia c. loss of depth perception d. aphasia e. lack of situational awareness
a. impulse control difficulty b. left hemiplegia c. loss of depth perception e. lack of situational awareness ATI
For a patient who had a right hemisphere stroke the nurse establishes a nursing diagnosis of a. risk for injury related to denial of deficits and impulsiveness. b. impaired physical mobility related to right-sided hemiplegia. c. impaired verbal communication related to speech-language deficits. d. ineffective coping related to depression and distress about disability.
a. risk for injury related to denial of deficits and impulsiveness.
drug therapy for ischemic stroke
alteplase (tPA) within 3-4.5 hrs of symptom onset
ataxia
an impaired ability to coordinate movement, often characterized by a staggering gait and postural imbalance
A female patient has left-sided hemiplegia after an ischemic stroke 4 days earlier. How should the nurse promote skin integrity? a. Position the patient on her weak side the majority of the time. b. Alternate the patient's positioning between supine and side-lying. c. Avoid the use of pillows in order to promote independence in positioning. d. Establish a schedule for the massage of areas where skin breakdown emerges.
b. Alternate the patient's positioning between supine and side-lying. MS
The nurse would expect to find what clinical manifestation in a patient admitted with a left-sided stroke? a. Impulsivity b. Impaired speech c. Left-side neglect d. Short attention span
b. Impaired speech MS ch 57
A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention? a. teach the client to scan to the right to see objects on the right side of her body b. place the bedside table on the right side of the bed c. orient the client to the food on her place using the clock method d. place the wheelchair on the client's left side
b. place the bedside table on the right side of the bed ATI
A diagnosis of a ruptured cerebral aneurysm has been made in a patient with manifestations of a stroke. The nurse anticipates that treatment options that would be evaluated for the patient include a. hyperventilation therapy b. surgical clipping of the aneurysm c. administration of hyperosmotic agents d. administration of thrombolytic therapy
b. surgical clipping of the aneurysm workbook
When providing care to the patient with an acute stroke, which duty can be delegated to the LPN/LVN? a. Screen patient for tPA eligibility. b. Assess the patient's ability to swallow. c. Administer scheduled anticoagulant medications. d. Place equipment needed for seizure precautions in room.
c. Administer scheduled anticoagulant medications. -screening and assessing are within the RN scope of practice -the UAP can place needed equipment in the room MS
Which of the following is the best treatment for acute ischemic stroke? a. heparin b. LMWH c. Alteplase d. Eptifibatie e. Warfarin
c. Alteplase
A 70-year-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? a. Monitor the blood pressure. b. Send the patient for a computed tomography (CT) scan. c. Check the respiratory rate and effort. d. Assess the Glasgow Coma Scale score.
c. Check the respiratory rate and effort. (initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway)
Which sensory-perceptual deficit is associated with left-sided 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
c. Slow and possibly fearful performance of tasks MS ch 57
Which intervention should the nurse delegate to the licensed practical nurse (LPN) when caring for a pt following an acute stroke? a. assess the pt's neurological status b. assess the pt's gag reflex before beginning feeding c. administer ordered antihypertensives and platelet inhibitors d. teach the pt's caregivers strategies to minimize unilateral neglect
c. administer ordered antihypertensives and platelet inhibitors workbook
A 47-year-old patient will attempt oral feedings for the first time since having a stroke. The nurse should assess the gag reflex and then 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.
c. assist the patient into a chair.
A pt with a stroke has right-sided hemiplegia. What does the nurse teach the family to prepare them to cope with the behavior changes seen with this type of stroke? a. ignore undesirable behaviors manifested by the pt b. provide directions to the pt verbally in small steps c. distract the pt from inappropriate emotional responses d. supervise all activities before allowing the pt to pursue them independently
c. distract the pt from inappropriate emotional responses (pts with left sided brain damage often experience mood swings and inappropriate emotional responses - this behavior is upsetting and embarrassing to both the pt and family so the pt should be distracted to minimize its presence) workbook
A nurse is assisting a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding? a. impulse control difficulty b. poor judgment c. inability to recognize familiar objects d. loss of depth perception
c. inability to recognize familiar objects ATI
In promoting health maintenance for prevention of strokes, the nurse understands that the highest risk for the most common type of stroke is present in which people? a. African Americans b. women who smoke c. individuals with hypertension and diabetes d. those who are obese with high dietary fat intake
c. individuals with hypertension and diabetes (most common stroke = thrombotic stroke) workbook
The pt has a lack of comprehension of both verbal and written language. Which type of communication difficulty does this pt have? a. dysarthria b. fluent dysphasia c. receptive aphasia d. expressive aphasia
c. receptive aphasia workbook
An appropriate food for a patient with a stroke who has mild dysphagia is a. fruit juices b. pureed meat c. scrambled eggs d. fortified milkshakes
c. scrambled eggs (soft foods that provide enough texture, flavor, and bulk to stimulate swallowing should be used for the patient with dysphasia) workbook
A pt with right hemisphere stroke has a nursing diagnosis of unilateral neglect related to sensory-perceptual deficits. During the pt's rehabilitation, what nursing intervention is important for the nurse to do? a. avoid positioning the pt on the affected side b. place all objets for care on the pt's unaffected side c. teach the pt to care consciously for the affected side d. protect the affected side from injury with pillows and supports
c. teach the pt to care consciously for the affected side -during the acute phase, the affected side is cared for by the nurse with positioning and support, but during rehab the pt is taught to care consciously for an attend to the affected side of the body to protect it from injury -pts may be positioned on the affected side for up to 30 min workbook
The nurse in a primary care provider's office is assessing several patients today. Which patient is most at risk for a stroke? a. A 92-yr-old female patient who takes warfarin (Coumadin) for atrial fibrillation b. A 28-yr-old male patient who uses marijuana after chemotherapy to control nausea c. A 42-yr-old female patient who takes oral contraceptives and has migraine headaches d. A 72-yr-old male patient who has hypertension and diabetes mellitus and smokes tobacco
d. A 72-yr-old male patient who has hypertension and diabetes mellitus and smokes tobacco MS ch 57
A 73-year-old patient with a stroke experiences facial drooping on the right side and right-sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find? a. Impulsive behavior b. Right-sided neglect c. Hyperactive left-sided tendon reflexes d. Difficulty comprehending instructions
d. Difficulty comprehending instructions (right facial drooping indicates left-sided brain damage)
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. 12-Lead electrocardiogram (ECG) d. Noncontrast computed tomography (CT) scan
d. Noncontrast computed tomography (CT) scan
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 (LOC). Which nursing diagnosis do they determine has the highest priority for the patient? a. Impaired physical mobility related to weakness b. Disturbed sensory perception related to brain injury c. Risk for impaired skin integrity related to immobility d. Risk for aspiration related to inability to protect airway
d. Risk for aspiration related to inability to protect airway (protection of the airway is the priority of nursing care for a patient having an acute stroke)
The female patient has been brought to the emergency department complaining of the most severe headache of her life. Which type of stroke should the nurse anticipate? a. TIA b. Embolic stroke c. Thrombotic stroke d. Subarachnoid hemorrhage
d. Subarachnoid hemorrhage MS ch 57
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 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).
d. The patient has atrial fibrillation and takes warfarin (Coumadin). (use of warfarin probably contributed to the intracerebral bleeding and remains a risk factor for further bleeding - vitamin K is needed to reverse the effects of the warfarin)
Which intervention is most appropriate when communicating with a patient with aphasia after a stroke? a. Present several thoughts at once so that the patient can connect the ideas. b. Ask open-ended questions to provide the patient the opportunity to speak. c. Finish the patient's sentences to minimize frustration associated with slow speech. d. Use simple, short sentences accompanied by visual cues to enhance comprehension.
d. Use simple, short sentences accompanied by visual cues to enhance comprehension. MS
A nursing intervention is indicated for the patient with hemiplegia is a. the use of a footboard to prevent plantar flexion b. immobilization of the affected arm against the chest with a sling c. positioning the patient in bed with each joint lower than the joint proximal to it d. having the patient perform passive ROM of the affected limb with the unaffected limb
d. having the patient perform passive ROM of the affected limb with the unaffected limb workbook
The priority intervention in the emergency department for the patient with a stroke is: a. intravenous fluid replacement b. administration of osmotic diuretics to reduce cerebral edema c. initiation of hypothermia to decrease the oxygen needs of the brain d. maintenance of respiratory function with a patent airway and oxygen administration
d. maintenance of respiratory function with a patent airway and oxygen administration workbook
Information provided by the patient that would help differentiate a hemorrhagic stroke from a thrombotic stroke includes: a. sensory disturbance b. a history of hypertension c. presence of motor weakness d. sudden onset of severe headache
d. sudden onset of severe headache MS ch 57
ischemic vs hemorrhagic stroke: onset
hemorrhagic stroke: severe headache, "worst headache of my life"
agnosia
inability to recognize familiar objects
agraphia
inability to write
embolic stroke
ischemic stroke caused by an embolus traveling from another part of the body to a cerebral artery
thrombotic stroke
ischemic stroke that occurs secondary to the development of a blood clot in a cerebral artery
agnosia: left or right sided brain damage?
left sided brain damage
aphasia: left or right sided brain damage?
left sided brain damage
depression, anger, easily frustrated: left or right sided brain damage?
left sided brain damage
hemiplegia of the right side of the body
left sided brain damage
slow, cautious behavior: left or right sided brain damage?
left sided brain damage
apraxia
loss of ability to execute or carry out skilled movements or gestures, despite having the desire and physical ability to perform them
homonymous hemianopsia
loss of half of the field of view on the same side in both eyes
hemianopsia
loss of visual field in one or both eyes; blindness in half the visual field
stroke diagnostics
noncontrast CT scan (can distinguish between ischemic and hemorrhagic stroke and help determine the size and location of the stroke)
hemiplegia
paralysis
alexia
reading difficulty, word blindness
which type of hemorrhagic stroke is associated with head trauma?
subarachnoid hemorrhage
questions to ask regarding symptoms
symptom onset, nature, and duration -ischemic stroke can only be reversed if tPA is administered within 3-4.5 hrs of onset of symptoms -symptoms immediately following a head injury indicate hemorrhagic stroke (vs ischemic stroke)
hemiparesis
weakness