Chapter 38: Caring for Clients with Cerebrovascular Disorders

A woman has been brought to the emergency department (ED) by her distraught husband who believes that she has had a stroke. A rapid assessment by the care team confirms that the husband's suspicions are likely accurate, and the woman is being screened for the possible administration of recombinant tissue plasminogen activator (r tPA). Which of the following factors would contraindicate the use of tPA? a. The woman's stroke has a hemorrhagic etiology. b. The woman is older than 80 years of age. c. The woman has previously had a stroke. d. The woman has hypertension and type 1 diabetes.

a tPA is contraindicated in hemorrhagic stroke because it would greatly exacerbate cerebral bleeding. Older age, previous stroke, hypertension, and diabetes do not necessarily contraindicate the use of tPA.

A nurse is completing discharge teaching for the client who has left-sided hemiparesis following a stroke. When investigating the client's home environment, the nurse should focus on which nursing diagnosis? a. Risk for injury b. Ineffective coping c. Noncompliance d. Diarrhea

a Because of decreased physical mobility, a client with recent left-sided hemiparesis is at risk for falls in the home setting. His ability to cope with the stroke is important, but investigating the home environment doesn't provide information about this nursing diagnosis. Diarrhea and Noncompliance aren't related to the client's home environment.

A stroke victim is experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe? a. Frontal b. Occipital c. Parietal d. Temporal

a 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 a lack of motivation.

Nursing care during the immediate recovery period from an ischemic stroke should include which of the following? a. Positioning to avoid hypoxia b. Maximizing PaCO2 c. Administering hypertonic IV solution d. Initiating early mobilization

a Interventions during this period include measures to reduce ICP, such as administering an osmotic diuretic (e.g., mannitol) and positioning to avoid hypoxia. Hypertonic IV solutions are not used unless sodium depletion is evident. PaCO2 must remain within an acceptable range, not maximized. Mobilization would take place after the immediate threat of increased ICP has past.

An emergency department nurse is awaiting the arrival of a client with signs of an ischemic stroke that began 1 hour ago, as reported by emergency medical personnel. The treatment window for thrombolytic therapy is which of the following? a. Three hours b. One hour c. Two hours d. Six hours

a Rapid diagnosis of stroke and initiation of thrombolytic therapy (within 3 hours) in clients with ischemic stroke leads to a decrease in the size of the stroke and an overall improvement in functional outcome after 3 months.

A client reports light-headedness, speech disturbance, and left-sided weakness that have lasted for several hours. In the examination, an abnormal sound is auscultated in an artery leading to the brain. What is the term for the auscultated discovery? a. bruit b. diplopia c. atherosclerotic plaque d. TIA

a A neurologic examination during an attack reveals neurologic deficits. Auscultation of the artery may reveal a bruit (abnormal sound caused by blood flowing over a rough surface within one or both carotid arteries). The term for the auscultated discovery is "bruit."

A patient who just suffered a hemorrhagic stroke is brought to the emergency department by ambulance. What should be the nurse's primary assessment focus? a. Cardiac and respiratory status b. Seizure activity c. Urinary output d. Fluid and electrolyte balance

a Acute care begins with managing the ABC's. Patients may have difficulty keeping an open and clear airway secondary to decreased level of consciousness. Neurological assessment with close monitoring for signs of increased neurological deficit and seizure activity occurs next. Fluid and electrolyte balance must be controlled carefully, with the goal of adequate hydration to promote perfusion and decrease further brain damage.

A client who has experienced an ischemic stroke has been admitted to the medical unit. The client's family is adamant that she remain on bed rest to hasten her recovery and to conserve energy. What principle of care should inform the nurse's response to the family? a. The client should mobilize as soon as she is physically able. b. To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks. c. The client should remain on bed rest until she expresses a desire to mobilize. d. Lack of mobility will greatly increase the client's risk of stroke recurrence.

a As soon as possible, the client is assisted out of bed and an active rehabilitation program is started. Delaying mobility causes complications, but not necessarily stroke recurrence. Mobility should not be withheld until the client initiates.

Which of the following, if left untreated, can lead to an ischemic stroke? a. Atrial fibrillation b. Cerebral aneurysm c. Arteriovenous malformation (AVM) d. Ruptured cerebral arteries

a Atrial fibrillation is the most frequently diagnosed arrhythmia in the United States. If left untreated, it can lead to an ischemic stroke. Cerebral hemorrhage, arteriovenous malformation, and cerebral hemorrhage can lead to a hemorrhagic stroke. Cerebral aneurysm, arteriovenous malformations, and ruptured cerebral arteries can lead to hemorrhagic stroke.

A client with a new diagnosis of amyotrophic lateral sclerosis (ALS) is overwhelmed by his diagnosis and the known complications of the disease. How can the client best make known his wishes for care as his disease progresses? a. Prepare an advance directive. b. Designate a most responsible health care provider (MRP) early in the course of the disease. c. Collaborate with representatives from the Amyotrophic Lateral Sclerosis Association. d. Ensure that witnesses are present when he provides instruction.

a Clients with ALS are encouraged to complete an advance directive or "living will" to preserve their autonomy in decision making. None of the other listed actions constitutes a legally binding statement of end-of-life care.

A nurse is teaching a community class that those experiencing symptoms of ischemic stroke need to enter the medical system early. The primary reason for this is which of the following? a. Thrombolytic therapy has a time window of only 3 hours. b. A ruptured intracranial aneurysm must quickly be repaired. c. Intracranial pressure is increased by a space-occupying bleed. d. A ruptured arteriovenous malformation will cause deficits until it is stopped.

a Currently approved thrombolytic therapy for ischemic strokes has a treatment window of only 3 hours after the onset of symptoms. Urgency is needed on the part of the public for rapid entry into the medical system. The other three choices are related to hemorrhagic strokes.

A nurse is providing care to a client who has had a stroke. Which symptoms are consistent with right-sided stroke? a. expressive aphasia, defects in the right visual fields, problems with abstract thinking b. impulsive behavior, poor judgment, deficits in left visual fields c. problems with abstract thinking, impairment of short-term memory, poor judgment d. cautious behavior, deficits in left visual fields, misjudgment of distances

b A nurse is providing care to a client who has had a stroke. Which symptoms are consistent with right-sided stroke? expressive aphasia, defects in the right visual fields, problems with abstract thinking impulsive behavior, poor judgment, deficits in left visual fields problems with abstract thinking, impairment of short-term memory, poor judgment cautious behavior, deficits in left visual fields, misjudgment of distances

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: a. Spatial-perceptual deficits. b. Left visual field deficit. c. Right-sided paralysis. d. Impulsive behavior.

c A left hemispheric stroke will cause right-sided weakness or paralysis. Because upper motor neurons decussate, a disturbance on one side of the body can cause damage on the opposite side of the brain. Refer to Box 47-2 in the text.

A client diagnosed with a hemorrhagic stroke has been admitted to the neurologic ICU. The nurse knows that teaching for the client and family needs to begin as soon as the client is settled on the unit and will continue until the client is discharged. What will family education need to include? a. How to differentiate between hemorrhagic and ischemic stroke b. Risk factors for ischemic stroke c. How to correctly modify the home environment d. Techniques for adjusting the client's medication dosages at home

c For a client with a hemorrhagic stroke, teaching addresses the use of assistive devices or modification of the home environment to help the client live with the disability. This is more important to the client's needs than knowing about risk factors for ischemic stroke. It is not necessary for the family to differentiate between different types of strokes. Medication regimens should never be altered without consultation.

The nurse is preparing health education for a client who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in this education? a. Mild, intermittent seizures can be expected. b. Take ibuprofen for complaints of a serious headache. c. Take antihypertensive medication as prescribed. d. Drowsiness is normal for the first week after discharge.

c The client and family are provided with information that will enable them to cooperate with the care and restrictions required during the acute phase of hemorrhagic stroke and to prepare the client to return home. Client and family teaching includes information about the causes of hemorrhagic stroke and its possible consequences. Symptoms of hydrocephalus include gradual onset of drowsiness and behavioral changes. Hypertension is the most serious risk factor, suggesting that appropriate antihypertensive treatment is essential for a client being discharged. Seizure activity is not normal; complaints of a serious headache should be reported to the health care provider before any medication is taken. Drowsiness is not normal or expected.

The pathophysiology of an ischemic stroke involves the ischemic cascade, which includes the following steps: 1. Change in pH 2. Blood flow decreases 3. A switch to anaerobic respiration <wbr /> 4. Membrane pumps fail 5. Cells cease to function 6. Lactic acid is generated Put these steps in order in which they occur. a. 635241 b. 352416 c. 236145 d. 162534

c The ischemic cascade begins when cerebral blood flow decreases to less than 25 mL per 100 g of blood per minute. At this point, neurons are no longer able to maintain aerobic respiration. The mitochondria must then switch to anaerobic respiration, which generates large amounts of lactic acid, causing a change in the pH. This switch to the less efficient anaerobic respiration also renders the neuron incapable of producing sufficient quantities of adenosine triphosphate (ATP) to fuel the depolarization processes. The membrane pumps that maintain electrolyte balances begin to fail, and the cells cease to function.

A client with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the client's cardiac and neurologic status, the nurse monitors the client for signs of what complication? a. Acute pain b. Septicemia c. Bleeding d. Seizures

c Bleeding is the most common side effect of t-PA administration, and the client is closely monitored for any bleeding. Septicemia, pain, and seizures are much less likely to result from thrombolytic therapy.

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? a. large-artery thrombotic b. small, penetrating artery thrombotic c. cardio embolic d. cryptogenic

c 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.

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. 2:00 p.m. b. 3:00 p.m. c. 4:00 p.m. d. 7:00 p.m.

c 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 client is diagnosed with a right-sided stroke. The client is now experiencing hemianopsia. How might the nurse help the client manage her potential sensory and perceptional difficulties? a. Keep the lighting in the client's room low. b. Place the client's clock on the affected side. c. Approach the client on the side where vision is impaired. d. Place the client's extremities where she can see them.

d The client with homonymous hemianopsia (loss of half of the visual field) turns away from the affected side of the body and tends to neglect that side and the space on that side; this is called amorphosynthesis. In such instances, the client cannot see food on half of the tray, and only half of the room is visible. It is important for the nurse to remind the client constantly of the other side of the body, to maintain alignment of the extremities, and if possible, to place the extremities where the client can see them. Clients with a decreased field of vision should be approached on the side where visual perception is intact. All visual stimuli (clock, calendar, and television) should be placed on this side. The client can be taught to turn the head in the direction of the defective visual field to compensate for this loss. Increasing the natural or artificial lighting in the room and providing eyeglasses are important in increasing vision. There is no reason to keep the lights dim.

A client recovering from a stroke has severe shoulder pain from subluxation of the shoulder. To prevent further injury and pain, the nurse caring for this client is aware of what principle of care? a. The client should be fitted with a cast because use of a sling should be avoided due to adduction of the affected shoulder. b. Elevation of the arm and hand can lead to further complications associated with edema. c. Passively exercising the affected extremity is avoided in order to minimize pain. d. The client should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder.

d To prevent shoulder pain, the nurse should never lift a client by the flaccid shoulder or pull on the affected arm or shoulder. The client is taught how to move and exercise the affected arm/shoulder through proper movement and positioning. The client is instructed to interlace the fingers, place the palms together, and push the clasped hands slowly forward to bring the scapulae forward; he or she then raises both hands above the head. This is repeated throughout the day. The use of a properly worn sling when the client is out of bed prevents the paralyzed upper extremity from dangling without support. Range-of-motion exercises are still vitally important in preventing a frozen shoulder and ultimately atrophy of subcutaneous tissues, which can cause more pain. Elevation of the arm and hand is also important in preventing dependent edema of the hand.

A physician orders therapy with tissue plasminogen activator for a client. The nurse alerts the physician to a potential problem when reviewing the client's chart and seeing that the client had major surgery within the last:

14 An exclusion criterion for therapy with tissue plasminogen activator is major surgery or invasive procedure within the past 14 days.

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 mg

A client has a 12-year history of migraine headaches and is frustrated over how these headaches impact lifestyle. What would the nurse indicate to the client is the origin of migraines? a. vascular b. muscular c. light d. endocrine

a Migraine headaches, which are recurrent and severe and last for a day or more, have a vascular origin.

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.

a Warmth promotes vasodilation; cool stimuli reduce blood flow.

The nurse is preparing discharge teaching for a patient who is being discharged after hospitalization for a hemorrhagic stroke. What should be included in the discharge teaching for this patient? a. Intermittent seizures can be expected. b. Take ibuprofen for complaints of a serious headache. c. Take antihypertensive medication as ordered. d. Drowsiness is normal for the first week after discharge.

c The patient and family are provided with information that will enable them to cooperate with the care and restrictions required during the acute phase of hemorrhagic stroke and to prepare them to return home. Patient and family teaching includes information about the causes of hemorrhagic stroke and its possible consequences. Symptoms of hydrocephalus include gradual onset of drowsiness and behavioral changes. Hypertension is the most serious risk factor, suggesting that appropriate antihypertensive treatment is essential for a patient being discharged. Seizure activity is not normal; complaints of a serious headache should be called to the health care provider before any medication is taken. Drowsiness is not normal.

The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient? a. High-Fowler's b. Prone c. Supine d. Semi-Fowler's

d The head of the bed is elevated 15 to 30 degrees (semi-Fowler's position) to promote venous drainage and decrease intracranial pressure.

The nurse is providing diet-related advice to a client who experienced a cerebrovascular accident (CVA). The client wants to minimize his volume of food and yet meet all nutritional requirements. To control the volume of food intake, the nurse should suggest that the client consume: a. thickened commercial beverages and fortified cooked cereals. b. dry or crisp foods and chewy meats. c. hot or tepid foods. d. a high-fat diet.

a Clients with CVA or other cerebrovascular disorders should lose weight and, therefore, should minimize their volume of food consumption. To ensure this, the nurse may suggest thickened commercial beverages, fortified cooked cereals, or scrambled eggs.

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: a. unknown. b. muscular. c. vasodilating agents. d. endocrine.

a Although cluster headaches can be triggered by vasodilating agents, the cause of cluster headaches is unknown.

The nurse is providing nonpharmacologic interventions for pain relief to a client with a tension headache. Which techniques may the nurse use? Select all that apply. a. Use guided imagery. b. Play soothing music. c. Allow interactions with friends and family members. d. Allow watching TV.

a, b Guided imagery and soothing music can reduce tension and relieve a tension headache. Stimuli should be reduced to help alleviate anxiety and reduce pain.

A client has suffered several migraines per month for the last 4 months. The physician prescribes prophylactic drug therapy. What is the rationale behind this action? Select all that apply. a. possible reduction in frequency of attacks b. possible reduction of migraine intensity c. possible reduction in migraine duration d. prevention of all migraines

a, b, c Prophylactic drug therapy may be necessary if migraine headaches occur several times a month and produce severe impairment, or if acute attacks are not adequately relieved. Although this may not prevent all migraines, it may reduce the duration, frequency, and intensity of attacks.

A family member brings the client to the clinic for a follow-up visit after a stroke. The family member asks the nurse what he can do to decrease his chance of having another stroke. What would be the nurse's best answer? a. "Have your heart checked regularly." b. "Stop smoking as soon as possible." c. "Take your prescribed medication to bring down your sodium levels." d. "Eat a nutritious diet."

b Smoking is a modifiable and highly significant risk factor for stroke. The significance of smoking, and the potential benefits of quitting, exceed the roles of sodium, diet, and regular medical assessments.

A family member brings the client to the clinic for a follow-up visit after a stroke. The family member asks the nurse what he can do to decrease his chance of having another stroke. What would be the nurse's best answer? a. "Have your heart checked regularly." b. "Stop smoking as soon as possible." c. "Take your prescribed medication to bring down your sodium levels." e. "Eat a nutritious diet."

b Smoking is a modifiable and highly significant risk factor for stroke. The significance of smoking, and the potential benefits of quitting, exceed the roles of sodium, diet, and regular medical assessments.

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? a. Large artery thrombosis b. Cerebral aneurysm c. Cardiogenic emboli d. Small artery thrombosis

b A cerebral aneurysm is a type of hemorrhagic stroke that is characterized by an exploding headache.

A nurse is caring for a client diagnosed with a hemorrhagic stroke. When creating this client's plan of care, what goal should be prioritized? a. Prevent complications of immobility. b. Maintain and improve cerebral tissue perfusion. c. Relieve anxiety and pain. d. Relieve sensory deprivation.

b Each of the listed goals is appropriate in the care of a client recovering from a stroke. However, promoting cerebral perfusion is a priority physiologic need, on which the client's survival depends.

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? a. The patient has new onset diabetes. b. This is significant for poor neurologic outcomes. c. The patient has developed diabetes insipidus due to the location of the stroke. d. The patient has liver failure.

b Hyperglycemia has been associated with poor neurologic outcomes in acute stroke and should be treated if the blood glucose is above 140 mg/dL (Summers et al., 2009).

If warfarin is contraindicated as a treatment for stroke, which medication is the best option? a. Dipyridamole b. Aspirin c. Clopidogrel d. Ticlodipine

b If warfarin is contraindicated, aspirin is the best option, although other medications may be used if both are contraindicated.

A patient who has had a previous stroke and is taking warfarin tells the nurse that he started taking garlic to help reduce his blood pressure. The nurse knows that garlic when taken together with warfarin will produce which type of interaction? a. No drug to drug interactions, may be taken together b. Can greatly increase the international normalization ratio (INR), increasing the risk of bleeding c. Can cause platelet aggregation, increasing the risk of blood clotting d. May increase cerebral blood flow, causing migraine headaches

b Taken together warfarin and garlic can greatly increase the INR, increasing the risk of bleeding

Which clinical manifestation would be exhibited by a client following a hemorrhagic stroke of the right hemisphere? a. Inability to move the right arm b. Neglect of the left side c. Neglect of the right side d. Expressive aphasia

b This client would have deficits on the left side. Expressive aphasia typically occurs with left-hemisphere stroke.

A community health nurse is conducting a workshop for unlicensed care providers who work in a chain of long-term care facilities. The nurse is teaching the participants about the signs and symptoms of stroke. What signs and symptoms should the nurse identify? Select all that apply. a. Epistaxis (nosebleed) b. Confusion c. Sudden numbness d. Sudden ear pain e. Visual disturbances

b, c, e The most common symptoms of stroke include numbness or weakness of the face, arm, or leg, especially on one side of the body; confusion or change in mental status; trouble speaking or understanding speech; visual disturbances; difficulty walking, dizziness, or loss of balance or coordination; and sudden, severe headache.

A nurse who provides care at a community clinic is in contact with a diverse group of patients. Which of the following individuals most clearly displays risk factors for stroke? a. A man who is receiving oral antibiotics for the treatment of a chlamydial infection b. A woman who has osteoporosis, a history of fractures, and a family history of stroke c. An obese woman with a history of atrial fibrillation and type 2 diabetes d. A 70-year-old man who has benign prostatic hyperplasia and early stage Alzheimer's disease

c Obesity, atrial fibrillation, and type 2 diabetes are all highly significant risk factors for stroke. None of the other listed individuals displays multiple risk factors for stroke.

A client diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for what purpose? a. To decrease cerebral edema b. To prevent seizure activity that is common following a TIA c. To remove atherosclerotic plaques blocking cerebral flow d. To determine the cause of the TIA

c The main surgical procedure for select clients with TIAs is carotid endarterectomy, the removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in clients with occlusive disease of the extracranial arteries. An endarterectomy does not decrease cerebral edema, prevent seizure activity, or determine the cause of a TIA.

A patient diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for what purpose? a. To decrease cerebral edema b. To prevent seizure activity that is common following a TIA c. To prevent a stroke by removing atherosclerotic plaques blocking cerebral flow d. To determine the cause of the TIA

c The main surgical procedure for select patients with TIAs is carotid endarterectomy, the removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in patients with occlusive disease of the extra cranial arteries. An endarterectomy does not decrease cerebral edema, prevent seizure activity, or determine the cause of a TIA.

A nursing student is writing a care plan for a newly admitted client who has been diagnosed with a stroke. What major nursing diagnosis should most likely be included in the client's plan of care? a. Adult failure to thrive b. Post-trauma syndrome c. Hyperthermia d. Disturbed sensory perception

d The client who has experienced a stroke is at a high risk for disturbed sensory perception. Stroke is associated with multiple other nursing diagnoses, but hyperthermia, adult failure to thrive, and post-trauma syndrome are not among these.

A client diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse? a. Sit with the client for a few minutes. b. Administer an analgesic. c. Inform the nurse manager. d. Call the health care provider immediately.

d A headache may be an indication that the aneurysm is leaking. The nurse should notify the health care provider immediately. The health care provider will decide whether administration of an analgesic is indicated. Informing the nurse manager is not necessary. Sitting with the client is appropriate, once the health care provider has been notified of the change in the client's condition.

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: a. Obesity b. Dyslipidemia c. Smoking d. Hypertension

d Hypertension is the most modifiable risk factor for either ischemic or hemorrhagic stroke. Unfortunately, it remains under-recognized and undertreated in most communities.

Which is the initial diagnostic test for a stroke? a. Carotid Doppler b. Electrocardiography c. Transcranial Doppler studies d. Noncontrast computed tomography

d The initial diagnostic test for a stroke is nonconstrast computed tomography performed emergently to determine whether the event is ischemic or hemorrhagic. Further diagnostics include a carotid Doppler, electrocardiogram, and transcranial Doppler.

What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke? a. Left visual field deficit b. Aphasia c. Slow, cautious behavior d. Altered intellectual ability

a A left visual field deficit is a common clinical manifestation of a right hemispheric stroke. Aphasia, slow, cautious behavior, and altered intellectual ability are all clinical manifestations of a left hemispheric stroke.

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

a 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.

When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke? a. The day before the patient is discharged b. After the patient has passed the acute phase of the stroke c. After the nurse has received the discharge orders d. The day the patient has the stroke

b Although rehabilitation begins on the day the patient has the stroke, the process is intensified during convalescence and requires a coordinated team effort.

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? a. Diphenhydramine (Benadryl) b. Lioresal (Baclofen) c. Heparin d. Pregabalin (Lyrica)

b 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) (Teasell, Foley, Pereira, et al., 2012). Other treatments for spasticity may include stretching, splinting, and oral medications such as baclofen (Lioresal).

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? a. Positioning the client to prevent airway obstruction b. Keeping the client in one position to decrease bleeding c. Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess d. Maintaining the client in a quiet environment

b The student nurse shouldn't keep the client in one position. She should carefully reposition the client often (at least every hour). The client needs to be positioned so that a patent airway can be maintained. Fluid administration must be closely monitored to prevent complications such as increased intracranial pressure. The client must be maintained in a quiet environment to decrease the risk of rebleeding.

After a seizure, the nurse should place the patient in which of the following positions to prevent complications? a. High Fowler's, to prevent aspiration b. Side-lying, to facilitate drainage of oral secretions c. Supine, to rest the muscles of the extremities d. Semi-Fowler's, to promote breathing

b To prevent complications, the patient is placed in the side-lying position to facilitate drainage of oral secretions, and suctioning is performed, if needed, to maintain a patent airway and prevent aspiration.

From which direction should a nurse approach a client who is blind in the right eye? a. From directly in front of the client b. From the right side of the client c. From the left side of the client d. From directly behind the client

c The nurse should approach the client from the left side so that the client can be aware of the nurse's approach. Likewise, personal items should be placed on the client's left side so that he can see them easily.

A client reports light-headedness, speech disturbance, and left-sided weakness lasting for several hours. The neurologist diagnosed a transient ischemic attack, which caused the client great concern. What would the nurse include during client education? a. When symptoms cease, the client will return to presymptomatic state. b. A TIA is an insidious, often chronic episode of neurologic impairment. c. Symptoms of a TIA may linger for up to a week. d. Two thirds of people that experience a TIA will go on to develop a stroke.

a Impaired blood circulation can be caused by arteriosclerosis, cardiac disease, or diabetes. A TIA is a sudden, brief episode of neurologic impairment. Symptoms may disappear within 1 hour; some continue for as long as 1 day. One third of people who experience a TIA subsequently develop a stroke.

Which of the following statements reflects nursing management of the patient with expressive aphasia? a. Encourage the patient to repeat sounds of the alphabet. b. Speak clearly and in simple sentences; use gestures or pictures when able. c. Speak slowly and clearly to assist the patient in forming the sounds. d. Frequently reorient the patient to time, place, and situation.

a Nursing management of the patient with expressive aphasia includes encouraging the patient to repeat sounds of the alphabet. Nursing management of the patient with global aphasia includes speaking clearly and in simple sentences and using gestures or pictures when able. Nursing management of the patient with receptive aphasia includes speaking slowing and clearly to assist the patient in forming the sounds. Nursing management of the patient with cognitive deficits, such as memory loss, includes frequently reorienting the patient to time, place, and situation.

To meet the sensory needs of a client with viral meningitis, the nurse should: a. minimize exposure to bright lights and noise. b. promote an active range of motion. c. increase environmental stimuli. d. avoid physical contact between the client and family members.

a Photophobia and hypersensitivity to environmental stimuli are the common clinical manifestations of meningeal irritation and infection. Therefore, the nurse should provide a calm environment with less stressful stimuli. Physical activity may worsen symptoms; therefore, physical activity should be reduced. Family members do not need to be avoided. People diagnosed with viral meningitis should be instructed to thoroughly wash hands frequently.

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? a. seasonal changes b. reproductive hormone c. fluctuations d. specific food chemicals medications

a Researchers believe the contributing cofactors for the cause of migraines are from changes in serotonin receptors that promote dilation of cerebral blood vessels and pain intensification from neurochemicals released from the trigeminal nerve. It has been suggested that fluctuations in reproductive hormones, chemicals in certain foods, and medications can trigger migraines.

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. impaired cerebral circulation b. cardiac disease c. diabetes insipidus d. hypertension

a 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 client is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this client is aware that an absolute contraindication for thrombolytic therapy is what? a. Evidence of hemorrhagic stroke b. Blood pressure of ≥ 180/110 mm Hg c. Evidence of stroke evolution d. Previous thrombolytic therapy within the past 12 months

a Thrombolytic therapy would exacerbate a hemorrhagic stroke with potentially fatal consequences. Stroke evolution, high BP, or previous thrombolytic therapy does not contraindicate its safe and effective use.

A male patient with cerebrovascular accident (CVA) is prescribed medication to treat the disorder. The patient wants to know what other measures may help reduce CVA. Which of the following is an accurate suggestion for the patient? a. Reduce hypertension and high blood cholesterol levels. b. Increase body weight moderately. c. Increase the intake of proteins and carbohydrates. d. Increase the fluids and hydration.

a CVAs are prevented by reducing certain risk factors, such as hypertension, overweight, cardiac dysrhythmias (such as atrial fibrillation), and high blood cholesterol levels. Patients should not gain body weight. In addition, the increased intake of proteins, carbohydrates, or fluids does not help in reducing the risk of CVAs.

The nurse is discharging home a client who had a stroke. The client has a flaccid right arm and leg and is experiencing urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common client response to a change in body image? a. Confusion b. Uncertainty c. Depression d. Disassociation

c Depression is a common and serious problem in the client who has had a stroke. It can result from a profound disruption in his or her life and changes in total function, leaving the client with a loss of independence. The nurse needs to encourage the client to verbalize feelings to assess the effect of the stroke on self-esteem. Confusion, uncertainty, and disassociation are not the most common client response to a change in body image, although each can occur in some clients.

The nurse is participating in a health fair for stroke prevention. Which will the nurse say is a modifiable risk factor for ischemic stroke? a. Thyroid disease b. Social drinking c. Advanced age d. Smoking

d Modifiable risk factors for transient ischemic attack (TIA) and ischemic stroke include hypertension, type 1 diabetes, cardiac disease, smoking, and chronic alcoholism. Advanced age, gender, and race are nonmodifiable risk factors for stroke.

A clinic nurse is caring for a client diagnosed with migraine headaches. During the client teaching session, the client questions the nurse regarding alcohol consumption. What would the nurse be correct in telling the client about the effects of alcohol? a. Alcohol causes hormone fluctuations. b. Alcohol causes vasodilation of the blood vessels. c. Alcohol has an excitatory effect on the CNS. d. Alcohol diminishes endorphins in the brain.

b Alcohol causes vasodilation of the blood vessels and may exacerbate migraine headaches. Alcohol has a depressant effect on the CNS. Alcohol does not cause hormone fluctuations, nor does it decrease endorphins (morphine-like substances produced by the body) in the brain.

The nurse is reviewing the medication administration record of a female client who possesses numerous risk factors for stroke. Which of the woman's medications carries the greatest potential for reducing her risk of stroke? a. Naproxen 250 PO b.i.d. b. Calcium carbonate 1,000 mg PO b.i.d. c. Aspirin 81 mg PO o.d. d. Lorazepam 1 mg SL b.i.d. PRN

c Research findings suggest that low-dose aspirin may lower the risk of stroke in women who are at risk. Naproxen, lorazepam, and calcium supplements do not have this effect.

A neurologic nurse is reviewing seizures with a group of staff nurses. How should this nurse best describe the cause of a seizure? a. Sudden electrolyte changes throughout the brain b. A dysrhythmia in the peripheral nervous system c. A dysrhythmia in the nerve cells in one section of the brain d. Sudden disruptions in the blood flow throughout the brain

c The underlying cause of a seizure is an electrical disturbance (dysrhythmia) in the nerve cells in one section of the brain; these cells emit abnormal, recurring, uncontrolled electrical discharges. Seizures are not caused by changes in blood flow or electrolytes.

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. A thrombus formation at the site of the endarterectomy b. This is a normal occurrence after an endarterectomy and would not be a concern. c. Bleeding from the endarterectomy site d. Surgical wound infection

a Formation of a thrombus at the site of the endarterectomy is suspected if there is a sudden new onset of neurologic deficits, such as weakness on one side of the body.

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. a. Report changes in neurologic status as soon as a worsening trend is identified. b. Use a well-lighted room for assessments every 2 hours. c. Follow the healthcare provider's orders to increase fluid volume. d. Maintain the head of the bed at 30 degrees. e. Avoid any activities that cause a Valsalva maneuver.

a, d, e Cerebral aneurysm precautions are implemented for the patient with a diagnosis of aneurysm to provide a nonstimulating environment, prevent increases in intracranial pressure, and prevent further bleeding. The patient is placed on bed rest in a quiet, nonstressful environment, because activity, pain, and anxiety are thought to elevate the blood pressure, which may increase the risk for bleeding. The head of the bed is elevated 30 degrees to promote venous drainage and decrease intracranial pressure. Any activity that suddenly increases the blood pressure or obstructs venous return is avoided. This includes the Valsalva maneuver, straining, forceful sneezing, pushing oneself up in bed and acute flexion or rotation of the head and neck (which compromises the jugular veins). Stool softeners and mild laxatives are prescribed to prevent constipation, which can cause an increase in intracranial pressure. Dim lighting is helpful for photophobia. Increasing fluid volume does not affect brain bleeding.

A nurse is collaborating with the interdisciplinary team to help manage a client's recurrent headaches. What aspect of the client's health history should the nurse identify as a potential contributor to the client's headaches? a. The client leads a sedentary lifestyle. b. The client takes vitamin D and calcium supplements. c. The client takes vasodilators for the treatment of angina. d. The client has a pattern of weight loss followed by weight gain.

c Vasodilators are known to contribute to headaches. Weight fluctuations, sedentary lifestyle, and vitamin supplements are not known to have this effect.

A nurse in the ICU is providing care for a client who has been admitted with a hemorrhagic stroke. The nurse is performing frequent neurologic assessments and observes that the client is becoming progressively more drowsy over the course of the day. What is the nurse's best response to this assessment finding? a. Report this finding to the health care provider as an indication of decreased metabolism. b. Provide more stimulation to the client and monitor the client closely. c. Recognize this as the expected clinical course of a hemorrhagic stroke. d. Report this to the health care provider as a possible sign of clinical deterioration.

d Alteration in LOC often is the earliest sign of deterioration in a client with a hemorrhagic stroke. Drowsiness and slight slurring of speech may be early signs that the LOC is deteriorating. This finding is unlikely to be the result of metabolic changes and it is not expected. Stimulating a client with an acute stroke is usually contraindicated.

The nurse is caring for a client recovering from an ischemic stroke. What intervention best addresses a potential complication after an ischemic stroke? a. Providing frequent small meals rather than three larger meals b. Teaching the client to perform deep breathing and coughing exercises c. Keeping a urinary catheter in situ for the full duration of recovery d. Limiting intake of insoluble fiber

b Because pneumonia is a potential complication of stroke, deep breathing and coughing exercises should be encouraged unless contraindicated. No particular need exists to provide frequent meals and normally fiber intake should not be restricted. Urinary catheters should be discontinued as soon as possible.

A community health nurse is giving an educational presentation about stroke and heart disease at the local senior citizens' center. What nonmodifiable risk factor for stroke should the nurse cite? a. Female gender b. Asian race c. Advanced age d. Smoking

c Advanced age, male gender, and race are well-known nonmodifiable risk factors for stroke. Smoking is a modifiable risk.

The public health nurse is planning a health promotion campaign that reflects current epidemiologic trends. The nurse should know that hemorrhagic stroke currently accounts for what percentage of total strokes? a. 43% b. 33% c. 23% d. 13%

d Strokes can be divided into two major categories: ischemic (87%), in which vascular occlusion and significant hypoperfusion occur, and hemorrhagic (13%), in which there is extravasation of blood into the brain or subarachnoid space.

After a subarachnoid hemorrhage, the client's laboratory results indicate a serum sodium level of less than 126 mEq/L. What is the nurse's most appropriate action? a. Administer a bolus of normal saline as prescribed. b. Prepare the client for thrombolytic therapy as prescribed. c. Facilitate testing for hypothalamic dysfunction. d. Prepare to administer 3% NaCl by IV as prescribed.

d The client may be experiencing syndrome of inappropriate antidiuretic hormone (SIADH) or cerebral salt-wasting syndrome. The treatment most often is the use of IV hypertonic 3% saline. A normal saline bolus would exacerbate the problem and there is no indication for tests of hypothalamic function or thrombolytic therapy.

The nurse is performing stroke risk screenings at a hospital open house. The nurse has identified four clients who might be at risk for a stroke. Which client is likely at the highest risk for a hemorrhagic stroke? a. White female, age 60, with history of excessive alcohol intake b. White male, age 60, with history of uncontrolled hypertension c. Black male, age 60, with history of diabetes d. Black male, age 50, with history of smoking

b Uncontrolled hypertension is the primary cause of a hemorrhagic stroke. Control of hypertension, especially in individuals over 55 years of age, clearly reduces the risk for hemorrhagic stroke. Additional risk factors are increased age, male gender, and excessive alcohol intake. Another high-risk group includes Black people, where the incidence of first stroke is almost twice that as in White people.