Chapter 57, Nursing Management: Stroke
A patient discharged from the hospital after a stroke looks at an old photograph and breaks down, crying inconsolably. What should the nurse tell the patient and the family? Select all that apply. "Leave the patient alone for some time." "Try to find out why the patient is crying." "Frustration and depression are common during the first year after stroke." "Do not communicate with the patient on topics that make the patient cry." "Be patient during recovery and do not complain about these involuntary behaviors."
"Frustration and depression are common during the first year after stroke." "Be patient during recovery and do not complain about these involuntary behaviors."
The nurse is providing education on the drug clopidogrel for a patient who experienced a transient ischemic attack (TIA). Which patient statement indicates a need for further teaching? "I will let my dentist know that I started this medication." "I need to be careful to avoid cutting myself when working with sharp garden tools." "I need to check with my health care provider before taking any of my herbal supplements." "I need to keep in close contact with my health care provider because I need frequent blood tests to adjust the medication dose."
"I need to keep in close contact with my health care provider because I need frequent blood tests to adjust the medication dose."
The registered nurse is teaching a novice nurse about interventions for a patient with a stroke on the left side of the brain. Which statement by the novice nurse indicates a need for further teaching? "I should maintain a calm and relaxing environment." "I should refrain from scolding the patient during an emotional outburst." "I should refrain from distracting the patient during a sudden emotional outburst." "I should educate the patient and the family about emotional outbursts after stroke."
"I should refrain from distracting the patient during a sudden emotional outburst."
The registered nurse is teaching a student nurse about airway management for a patient who is at risk of aspiration. Which statement made by the student nurse indicates effective learning? "I will perform suctioning as needed." "I will discourage the patient from coughing." "I will encourage rapid breathing by the patient." "I will provide a small amount of food before the swallow evaluation."
"I will perform suctioning as needed."
The nurse is teaching a student nurse about implementing a bladder retraining program for a patient who sustained a hemorrhagic stroke. Which statement made by the student nurse indicates the need for further teaching? "I will assess for bladder distention." "I will observe for restlessness in the patient." "I will schedule the patient's toileting every 2 hours." "I will provide an adequate amount of fluid to the patient between 5:00 AM and 9:00 PM."
"I will provide an adequate amount of fluid to the patient between 5:00 AM and 9:00 PM."
The registered nurse is teaching a student nurse about the proper way to communicate with a patient who has aphasia due to a stroke. Which statement made by the student nurse indicates a need for further learning? "I will speak in a normal tone with the patient." "I will frame questions in a "Yes" or "No" format." "I will not pretend to understand the patient, if I do not." "I will try to force communication with the patient if the patient is upset."
"I will try to force communication with the patient if the patient is upset."
A patient is not able to talk properly after having a stroke but is able to understand what the nurse is saying. While talking to the patient, which sentence stated by the patient will confirm Broca's aphasia? Select all that apply. "Ice-cream eat." "My dog is thirsty." "Bird bird two tree." "You are very caring." "I like to go to the park."
"Ice-cream eat." "Bird bird two tree."
A nurse is admitting a patient with a thrombotic stroke. The patient is nothing by mouth (NPO) but is requesting a drink of water. Which response by a nurse is appropriate? "You can have a couple of ice chips to wet your mouth." "A barium swallow test is required for stroke patients before giving PO fluids." "We need to keep you NPO in case a procedure needs to be performed today." "It is not safe to allow you to have anything by mouth until a swallow assessment can be performed."
"It is not safe to allow you to have anything by mouth until a swallow assessment can be performed."
The registered nurse is teaching a student nurse about acute care for a patient with ischemic stroke. The patient's blood pressure is 230/120 mm Hg. Which statement made by the student nurse indicates the need for further teaching? "Urine output should be monitored." "Fibrinolytic therapy should be given." "Antihypertensive drugs should be provided." "Large amounts of fluid should be provided."
"Large amounts of fluid should be provided."
A relative of a stroke patient who is unable to walk is not sure about the benefits of mirror therapy. How will the nurse assure the relative? Select all that apply. "Mirror therapy will make use of a prosthetic leg." "Mirror therapy will provide you 100 percent relief." "Mirror therapy may improve the patient's ability to walk." "Mirror therapy is an additional intervention along with other treatments." "Mirror therapy is a complete treatment and will eliminate the need for medication post stroke."
"Mirror therapy may improve the patient's ability to walk." "Mirror therapy is an additional intervention along with other treatments."
A patient diagnosed with atrial fibrillation has been put on the oral anticoagulant warfarin. What instructions should the nurse give the patient? Select all that apply. "Stop the drug if you feel all right." "The drug requires close monitoring." "Lower the dose of the drug if you feel all right." "Do not take the drug if you are not comfortable." "Do not stop the drug without informing the doctor."
"The drug requires close monitoring." "Do not stop the drug without informing the doctor."
A lumbar puncture is to be performed for a patient with suspected subarachnoid hemorrhage. Which explanation would the nurse give about why this procedure was ordered? Select all that apply. "The lumbar puncture will measure brain temperature." "The lumbar puncture will assess for the presence of red blood cells in the cerebrospinal fluid." "The lumbar puncture will assess for increased intracranial pressure." "The lumbar puncture is a follow up study because your computed tomographic (CT) scan does not show hemorrhage." "The lumbar puncture will assess for an obstruction in the foramen magnum."
"The lumbar puncture will assess for the presence of red blood cells in the cerebrospinal fluid." "The lumbar puncture is a follow up study because your computed tomographic (CT) scan does not show hemorrhage."
A registered nurse is teaching a student nurse about the management of increased intracranial pressure in a patient who sustained a stroke. Which statement made by the student nurse indicates the need for further teaching? "The patient should be placed in a supine position." "The patient's head and neck should be in alignment." "The patient's bowel function status should be maintained." "The patient's temperature should be maintained between 96.8° F to 98.6° F."
"The patient should be placed in a supine position."
The nurse finds the wife of a patient who experienced a stroke one week ago crying in the hallway. The wife tells the nurse "I do not know if I can deal with this. He cries about everything and gets so moody with me." What is the best response by the nurse? "This must be very frustrating for you." "Depression is very common following a stroke." "How did he react to stress before the stroke?" "He cannot control how he reacts. This is something you need to accept."
"This must be very frustrating for you."
A patient is admitted to the emergency department with right-sided facial drooping. When taking the patient's history, which information would be most significant? "When did the facial drooping begin?" "Do you have a family history of stroke?" "Have you had facial drooping in the past?" "Are you having any pain on the right side of your face?"
"When did the facial drooping begin?"
While assessing the level of consciousness in a patient with a stroke, the nurse asks the patient the month and the patient's age. The patient knew his or her age but could not state what month it was. What score should the nurse give to the patient, using the National Institutes of Health Stroke Scale (NIHSS)? Record your answer using a whole number.
1
A patient has been admitted to the hospital with acute cerebral infarction. The patient is completely paralyzed on the left side and does not recognize the hand. Other neurologic functions are normal. According to the National Institutes of Health Stroke Scale (NIHSS), what is this patient's score? Record the answer using a whole number.
5
The brain requires a continuous supply of blood and oxygen. If it is interrupted, how quickly does cellular death occur? 2 minutes 5 minutes 30 minutes 30 seconds
5 minutes
What rate should blood flow in the brain in order to maintain function? 15 mL/100 g 25 mL/100 g 55 mL/100 g 70 mL/100 g
55 mL/100 g
A nurse is screening patients to determine if administering tissue plasminogen activator (tPA) for fibrinolytic therapy is an appropriate intervention. Which patients may be administered tPA safely? Select all that apply. A 30-year-old with hemophilia A A 70-year-old with blood sugar levels of 110 mg/dL A 40-year-old with history of head injury six months ago A 25-year-old with history of cholecystectomy two years previously A 35-year-old with a computed tomography (CT) scan showing hemorrhagic stroke
A 70-year-old with blood sugar levels of 110 mg/dL A 40-year-old with history of head injury six months ago A 25-year-old with history of cholecystectomy two years previously
Which medical condition places a patient at a higher risk for an embolic stroke? Atrial fibrillation Atherosclerosis Cancer of the brain Anticoagulant therapy
A FIB
A patient with a stroke develops aphasia. What does the nurse suspect to be the reason for the patient's condition? A defect in the vertebral artery A defect in the middle cerebral artery A defect in the anterior cerebral artery A defect in the posterior cerebral artery
A defect in the middle cerebral artery
When planning for venous thromboembolism (VTE) prevention, what should the nurse place as the highest priority ? Administration of daily enoxaparin injections. Application of compression stockings on legs. Active and passive range-of-motion (ROM) exercises. Use of sequential compression devices on lower legs.
Active and passive range-of-motion (ROM) exercises.
The primary health care provider has prescribed nimodipine. Which nursing action is appropriate? Hold if patient has expiratory wheezes. Administer for temperature greater than 101° F. Hold if diastolic blood pressure is less than 60 mm Hg. Administer if heart rate is greater than 60 beats/minute.
Administer if heart rate is greater than 60 beats/minute.
The nurse is preparing a community stroke awareness program. The nurse knows that which ethnic group has the highest incidence of stroke? Asians Mexicans Caucasians African Americans
African Americans
The nurse finds the patient is unable to recognize familiar objects after a stroke. What term does the nurse chart in the patients medical record? Alexia Agnosia Aphasia Agraphia
Agnosia
A patient is admitted with stroke. After initial assessment, the health care provider finds that the patient has spatial-perceptual alteration. Which manifestations should the nurse expect to find in the patient? Select all that apply. Agnosia Apraxia Akinesia Expressive aphasia Homonymous hemianopsia
Agnosia Apraxia Homonymous hemianopsia
A patient who has had a stroke is frustrated by mobility problems. What should the nurse do? Select all that apply. Ask the patient to maintain bed rest. Probe the patient about the reason for frustration. Allow family and friends to visit the patient more often. Speak to the patient in a calm, caring manner to reduce frustration. Help the family understand that frustration is common in the first year after a stroke.
Allow family and friends to visit the patient more often. Speak to the patient in a calm, caring manner to reduce frustration. Help the family understand that frustration is common in the first year after a stroke.
A patient has left-sided hemiplegia following an ischemic stroke that was experienced four days earlier. How should the nurse best promote the health of the patient's integumentary system? Position the patient on the weak side the majority of the time. Alternate the patient's positioning between supine and side-lying. Avoid the use of pillows to promote independence in positioning. Establish a schedule for the massage of areas where skin breakdown emerges.
Alternate the patient's positioning between supine and side-lying.
A patient sustained an ischemic stroke and is given an intravenous (IV) solution with glucose and water. What is the expected change that the nurse monitors in the patient? A decrease in urine output An increase in cerebral edema A decrease in intracranial pressure A maintained balance of fluids and electrolytes
An increase in cerebral edema
A patient has sustained a head injury and is suspected to have increased intracranial pressure. Which factor does the nurse recognize will improve cerebral blood flow? An increase in blood viscosity A decrease in carbon dioxide levels An increase in hydrogen ion concentration A high partial pressure of arterial oxygen
An increase in hydrogen ion concentration
During the acute stage of a stroke, it is important for the nurse to include which intervention for a patient experiencing aphasia? Ask simple yes and no questions. Limit verbal communication to reduce frustration. If the patient is unable to answer a question, divert eye contact to reduce embarrassment. If patient does not answer immediately, ask the patient if he or she understands or needs you to repeat the information.
Ask simple yes and no questions.
A patient suffered a stroke one day ago. Which aspects of care may only be performed by the registered nurse caring for this patient? Select all that apply. Assess neurologic status. Assess respiratory status. Measure and record urine output. Measure blood pressure frequently. Perform passive and active range-of-motion exercises.
Assess neurologic status. Assess respiratory status.
The nurse is reviewing a patient's chart for factors that may have predisposed the patient to a recent stroke. Which factors placed this patient at risk for the stroke and should be included in the nurse's teaching plan? Select all that apply. Atrial fibrillation Walks once a week Quit smoking in 1984 History of breast cancer History of urinary tract infections Drinks three glass of red wine daily
Atrial fibrillation Walks once a week Drinks three glass of red wine daily
A patient has suffered a right-brain stroke. What should the nurse include in the safety measures immediately after the stroke? Select all that apply. Avoid using vests. Restrain the patient. Elevate the side rails. Elevate the height of the bed. Use video monitors to observe the patient continuously.
Avoid using vests. Elevate the side rails. Use video monitors to observe the patient continuously.
A patient is diagnosed with a transient ischemic attack due to carotid artery disease. Which surgical procedure would the primary health care provider suggest for this patient, as depicted in the image? Stenting Carotid endarterectomy Transluminal angioplasty Extracranial-intracranial bypass
Carotid endarterectomy
A patient is suspected of having a subarachnoid hemorrhage. For which diagnostic test will the nurse prepare the patient, as the most reliable diagnostic study to identify the source of subarachnoid hemorrhage? Cardiac imaging Cerebral angiography Magnetic resonance angiography Computed tomography angiography
Cerebral angiography
A patient who sustained a stroke is to have a diagnostic test to determine cerebral blood flow. For what diagnostic test does the nurse prepare the patient? A. Echocardiography B. Cerebral angiography C. Magnetic resonance angiography D. Computed tomography angiography
Cerebral angiography
Which mechanism protects the brain and promotes its functioning? Collateral circulation Intracranial pressure Neurologic metabolism Cerebral autoregulation
Cerebral autoregulation
While assessing a patient with paralysis due to a hemorrhagic stroke, the registered nurse finds redness of the patient's skin. What would be the most appropriate intervention to prevent complications in the patient? Using emollients on the skin Changing the patient's position Providing good skin care and hygiene Using a special mattress for pressure relief
Changing the patient's position
A patient who sustained a hemorrhagic stroke and has increased intracranial pressure reports to the nurse about loose stools. What is the priority nursing action? Administering enemas Administering psyllium Checking for stool impaction Discouraging physical activity
Checking for stool impaction
A patient has sustained a stroke, and the nurse is scheduling ordered diagnostic studies to assess the patient's cardiac status. Which diagnostic tests are a priority for this patient? Select all that apply. Chest x-ray Cardiac markers Electrocardiogram Computed tomography Complete blood count
Chest x-ray Cardiac markers Electrocardiogram
The patient is scheduled for transluminal angioplasty and stenting. Which drug does the nurse anticipate will be prescribed? Apixaban Metoprolol Clopidogrel Simvastatin
Clopidogrel
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. Clopidogrel Enoxaparin Dipyridamole Enteric-coated aspirin Tissue plasminogen activator (tPA)
Clopidogrel Enoxaparin Dipyridamole Enteric-coated aspirin
A patient is admitted with a hemorrhagic stroke. Which prescription should a nurse question? Diltiazem 30 mg PO every eight hours Metoprolol succinate 50 mg PO once daily Clopidogrel 75 mg by mouth (PO) once daily Cefazolin 1 gm intravenous piggyback (IVPB) every eight hours
Clopidogrel 75 mg by mouth (PO) once daily
A patient presenting with stroke symptoms is being considered for fibrinolytic therapy. What assessment data would be important to communicate promptly to the prescribing health care provider? Presence of indwelling urinary catheter Removal of soft tissue tumor from back three weeks ago History of transient ischemic attack (TIA) six months ago Colonoscopy for evaluation of blood in the stools one week ago
Colonoscopy for evaluation of blood in the stools one week ago
The patient is recovering from a stroke and is confined to bed for most of the day. For which condition is this patient at risk? Fatigue Malnutrition Dehydration Constipation
Constipation
Immediately following a stroke, the patient's blood pressure (BP) is 80/60 mm Hg. Which action would the nurse take based on this finding? Select all that apply. Correct hypotension. Correct hypovolemia. Start intravenous glucose. Continue treatment for stroke. Check the blood glucose level.
Correct hypotension. Correct hypovolemia. Continue treatment for stroke.
The nurse is feeding a patient by mouth for the first time after a stroke. What should the nurse feed the patient at this first feeding? Thin liquids Pureed foods Crushed ice Milk products
Crushed ice
Which aspects of the medical history of a female patient who has had a stroke could be associated with the event? Select all that apply. Chronic low back pain. Current use of high-dose oral contraceptives. History of long-standing hair loss. History of migraine headaches with aura. Past employment involving exposure to chemical dyes.
Current use of high-dose oral contraceptives. History of migraine headaches with aura.
Which action can the nurse delegate to the unlicensed assistive personnel (UAP) to reduce fatigue for a patient recovering from a stroke at meal times? Feed the patient the meal. Provide water during the meal. Cut up the meat for the patient. Place the head of the bed at 30 degrees.
Cut up the meat for the patient.
The patient has a diagnosis of stroke. What is the priority nursing diagnosis for the nurse when planning care? Risk for aspiration Impaired swallowing Impaired verbal communication Decreased intracranial adaptive capacity
Decreased intracranial adaptive capacity
What would be the appropriate nursing intervention for optimizing musculoskeletal function of a patient with hemorrhagic stroke? Discouraging the use of lap boards Discouraging pulling the patient's arm Discouraging the use of trochanter roll Discouraging the use of posterior leg splints
Discouraging pulling the patient's arm
A patient who experienced a stroke on the left side of the brain suddenly begins to cry while playing a card game. What is the appropriate action by the nurse? Distract the patient. Ask the patient what made him or her cry. Sit with the patient until he or she stops crying. Reassure the patient that there is nothing to cry about.
Distract the patient.
The patient's vitals are a blood pressure (BP) of 180/100 mm Hg, a heart rate of 100 beats/minute, a respiratory rate of 22, and a body temperature of 98.9 F. The doctor has ordered labetalol by slow intravenous (IV) push. What is recommended for BP management after a stroke? A lower BP is a protective response to maintain cerebral perfusion. The BP must be lower than 180/105 mm Hg to receive fibrinolytic agents. Elevated BPs are expected after a stroke, and drug therapy should be initiated. Drugs to lower blood pressure are recommended if the BP is 220/120 mm Hg or higher.
Drugs to lower blood pressure are recommended if the BP is 220/120 mm Hg or higher.
The nurse is preparing a patient with a stroke for diagnostic testing to determine cerebral blood flow. Which tests would be of greatest benefit to obtain this information? Select all that apply. Duplex scanning Electroencephalogram (EEG) Digital subtraction angiography Transcranial Doppler ultrasonography Computed tomography perfusion and diffusion imaging
Duplex scanning Digital subtraction angiography Transcranial Doppler ultrasonography
A nurse is explaining methods to reduce the risk of a stroke to a patient. What instructions should the nurse convey to the patient? SATA. Limit fluid and fiber intake. Eat a diet low in saturated fats. Decrease level of physical exercise. Maintain a normal BP. Limit consumption of alcohol to moderate levels.
Eat a diet low in saturated fats. Maintain a normal BP. Limit consumption of alcohol to moderate levels.
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 w/o pain. The patient is unable to life the arm and says that it "just fell." What condition should the nurse suspect? Myopathy Fibromyalgia Embolic stroke Carpal tunnel syndrome
Embolic stroke
The nurse assesses atrial fibrillation on the cardiac monitor. What type of stroke does the nurse anticipate for the patient to experience, if left without treatment? Embolic stroke Thrombotic stroke Intracerebral hemorrhage Subarachnoid hemorrhage
Embolic stroke
A nurse is caring for stroke patients. What should the nurse include in the bladder retraining program of a stroke-affected patient? Select all that apply. Encourage adequate fluid intake. Observe for signs of restlessness. Assess bladder distention by palpation. Change the urinary catheters periodically. Place the bedpan near the bed at all times.
Encourage adequate fluid intake. Observe for signs of restlessness. Assess bladder distention by palpation.
A patient who had a stroke three days ago has constipation. What should be the first interventions? Select all that apply. Start laxatives. Give an enema. Provide suppositories. Encourage physical activity. Encourage fluid and fiber intake.
Encourage physical activity. Encourage fluid and fiber intake.
The primary health care provider finds neuromuscular and cognitive impairment in a patient with hemorrhagic stroke. Which nursing intervention is most appropriate for the nurse to include in the plan of care? Encouraging independent exercise Discouraging the use of splints to the limbs Scheduling exercise sessions one after another Allowing the patient to get out of bed independently
Encouraging independent exercise
A nurse assesses the blood pressure (BP) of a patient who had a stroke and finds it to be 166/96 mm Hg. What is the priority action by the nurse? Select all that apply. Ensure adequate fluid intake. Start oral antihypertensive drugs. Consider this as a protective response. Start intravenous antihypertensive drugs. Call the health care provider immediately.
Ensure adequate fluid intake. Consider this as a protective response.
The nurse assesses a patient experiencing visual disturbances and difficulty swallowing with a blood pressure of 280/180 mm Hg. What is the priority action by the nurse when the patient loses consciousness? Call the stroke team. Ensure patent airway. Perform pulse oximetry. Position head in midline.
Ensure patent airway.
A patient has experienced a right-brain stroke. What intervention would be most important to include in the plan of care? Allow extra time for transfer and activity. Evaluate body positioning during all transfers. Assist with self-catheterization every four hours. Provide activities that promote verbal memory skills.
Evaluate body positioning during all transfers.
Which assessments would the nurse conduct that will enhance detection and responsiveness in patients experiencing a stroke? Foot drop, leg weakness, speech difficulties, time Facial drooping, leg weakness, garbled speech, time Facial weakness, arm weakness, states disoriented Facial drooping, arm weakness, speech difficulties, time
Facial drooping, arm weakness, speech difficulties, time (FAST)
A patient has Broca's aphasia. Which lobe of the brain does the nurse anticipate to have been affected by a stroke? Frontal lobe Parietal lobe Occipital lobe Temporal lobe
Frontal
What should be included in the nursing plan for prevention of skin breakdown in a stroke patient? Select all that apply. Good skin hygiene Massaging the damaged area Applying emollients to dry skin Minimizing the frequency of position changes Administering back rubs with alcohol for a cooling effect
Good skin hygiene Applying emollients to dry skin
A patient is being discharged from the hospital after recovering from stroke. What food items should be included in the diet plan? Select all that apply. Pizza French fries Cheeseburger Grilled chicken Vegetable soups
Grilled chicken Vegetable soups
Which are primary methods of preventing a stroke? Select all that apply. Healthy diet Regular exercise Stroke rehabilitation Breast self-examination Knowing the signs of stroke Management of blood pressure
Healthy diet Regular exercise Management of blood pressure
The patient has a sudden onset of symptoms including headache and vomiting. The nurse observes that the patient is also drowsy. Which condition may this patient be experiencing? Embolic stroke Brain infarction Cerebral edema Hemorrhagic stroke
Hemorrhagic stroke
The nurse would expect to find what clinical manifestation in a patient admitted with a left-hemispheric stroke? Impulsivity Impaired speech Left-side neglect Short attention span
Impaired speech
What behavior is exhibited by a patient who has suffered a right-brain stroke? Very cautious Difficulty with words Impulsive and impatient Accomplishes tasks quickly
Impulsive and impatient
A patient has sustained a stroke on the right side of the brain. What clinical manifestations does the nurse determine to be associated with this type of injury? Impulsiveness Impaired speech Slow performance Paralyzed right side
Impulsiveness
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? Embolic stroke Thrombotic stroke Intracerebral hemorrhage Subarachnoid hemorrhage
Intracerebral hemorrhage
The nurse provides care for a patient who has had a transient ischemic attack (TIA). The patient's spouse asks about the significance of the condition. How should the nurse explain a TIA? It is usually neurologically damaging. It is a signal of progressive brain damage. It can be a warning of an impending stroke. It is nothing to be concerned about because it is not a stroke.
It can be a warning of an impending stroke.
A patient is scheduled for a serial computed tomography (CT) scan after a stroke. What should the nurse tell the patient and the patient's relatives about this procedure? Select all that apply. It helps to evaluate recovery. It helps to evaluate the activity of the brain. It helps to assess the effectiveness of treatment. It helps to identify problems with electrical conditions of the brain. It helps to identify side effects of drugs used after stroke on brain tissue.
It helps to evaluate recovery. It helps to assess the effectiveness of treatment.
A patient suspected of having a subarachnoid hemorrhage is scheduled to undergo transcranial Doppler (TCD). What information about this procedure should the nurse provide the patient and the patient's family? Select all that apply. It is an invasive procedure. It is effective in detecting microemboli. It requires a small dose of contrast media. It provides visualization of cerebral blood vessels. It measures the velocity of blood flowing through major vessels.
It is effective in detecting microemboli. It measures the velocity of blood flowing through major vessels.
A patient with a history of transient ischemic attack has been prescribed aspirin at a dose of 81 mg/day. What information about aspirin should be given to the patient? Select all that apply. It is only a pain medication. It should be taken twice daily before food. It is okay to lower the dose if you feel well. It may cause tinnitus, which should be reported immediately. It may cause bleeding, which should be reported immediately.
It may cause tinnitus, which should be reported immediately. It may cause bleeding, which should be reported immediately.
The patient is scheduled for a transcranial Doppler imaging scan. What information will this test provide? It measures the velocity of blood flow. It identifies red blood cells. It visualizes blood vessels. It measures oxygenation.
It measures the velocity of blood flow.
A patient has suffered a stroke. Which neurologic factor will the nurse assess and record? Speech Mobility Respiratory function Level of consciousness
LOC
The relatives of a patient suspected of having a stroke are concerned, because the doctor has asked the patient to undergo magnetic resonance imaging (MRI). What information will be included when explaining to the relatives the importance of undergoing MRI? Select all that apply. MRI helps to identify the likely causes of stroke. MRI helps to measure oxygenation and temperature of the brain. MRI helps to differentiate between a stroke and any other brain lesion. MRI helps to measure blood flow through major vessels. MRI helps to evaluate the progression of a stroke.
MRI helps to identify the likely causes of stroke. MRI helps to differentiate between a stroke and any other brain lesion.
During the acute phase of stroke management, the most important nursing intervention to decrease risk of aspiration is what? Placing an oral-pharyngeal airway. Elevating head of bed 30 degrees. Placing suction equipment at the bedside. Maintaining nothing by mouth (NPO) status.
Maintaining nothing by mouth (NPO) status.
A computed tomography (CT) scan of the head of a patient reveals that the patient has experienced a hemorrhagic stroke. What is the priority nursing intervention in the emergency department? Maintenance of the patient's airway Positioning to promote cerebral perfusion Control of fluid and electrolyte imbalances Administration of tissue plasminogen activator (tPA)
Maintenance of the patient's airway
A nurse is caring for a patient who has aphasia after suffering from a stroke. How will the nurse communicate with the patient? Select all that apply. Make use of gestures. Present only one thought at a time. Do not interrupt the patient if he or she is taking too long to communicate. Pretend to understand the patient even if he or she does not make sense. Keep communicating, even if the patient is upset, to help the patient change his or her mood.
Make use of gestures. Present only one thought at a time. Do not interrupt the patient if he or she is taking too long to communicate.
A nurse is preparing a menu for a stroke patient with dysphagia. What food should be included in the diet? Milkshakes Chicken soup Mashed potatoes Pureed cooked rice
Mashed potatoes
A patient is admitted to the hospital with a stroke. Which interventions should be included in the acute care of a stroke patient? Select all that apply. Monitor urine output. Monitor the blood sugar level. Ensure adequate fluid intake. Start 5% dextrose intravenously. Use medications to lower the blood pressure (BP).
Monitor urine output. Monitor the blood sugar level. Ensure adequate fluid intake.
A patient has been given an intraarterial infusion of tissue plasminogen activator (tPA) for ischemic stroke. What are the responsibilities of the nurse for 24 hours post treatment? Select all that apply. Monitor vital signs. Use anticoagulants. Start pain medication. Check blood pressure. Start intravenous glucose.
Monitor vital signs. Check blood pressure.
A nurse is caring for a patient who had a stroke and is at risk of venous thromboembolism (VTE). What should be included in the nursing interventions for such patients? Select all that apply. Note unusual warmth of legs. Measure the calf and thigh daily. Observe swelling of lower extremities. Ask the patient to minimize movements of limbs. Ask the patient to maintain bed rest to avoid swelling.
Note unusual warmth of legs. Measure the calf and thigh daily. Observe swelling of lower extremities.
A patient with known history of hypertension presents to the emergency department with the complaint of sudden severe headache with no known cause. What should the nurse do first? Perform eye examination. Perform reflex examination. Obtain a computed tomographic (CT) scan. Obtain orders for administering antihypertensives.
Obtain a computed tomographic (CT) scan.
A nurse is caring for a patient who is not able to swallow properly post stroke. What interventions are important to facilitate patient safety during eating? Select all that apply. Place food on the unaffected side of the mouth. Check mouth for pocketing of food. Place patient in a low Fowler's position. Help the patient maintain a sitting position for 30 minutes after a completing meal. Help the patient to position the head in backward extension to promote swallowing.
Place food on the unaffected side of the mouth. Check mouth for pocketing of food. Help the patient maintain a sitting position for 30 minutes after a completing meal.
What precautions should the nurse follow when feeding a patient with a stroke on the left side? Select all that apply. Place the patient in right lateral position. Place the patient in low Fowler's position. Place the patient in high Fowler's position. Place the patient in Trendelenburg's position. Place the patient in a chair with the head flexed forward.
Place the patient in high Fowler's position. Place the patient in a chair with the head flexed forward.
A patient presents to the emergency department reporting a sudden onset of headache described as "the worse headache ever." The patient also reports nausea and visual disturbances. What collaborative intervention is a priority for the nurse? Obtain consent for lumbar puncture. Administer zofran 4 mg Ondansetron (ODT) for nausea. Administer morphine sulfate 4 mg intravenous push (IVP). Prepare patient for transport to computed tomography (CT) scan.
Prepare patient for transport to computed tomography (CT) scan.
A patient who has been diagnosed with stroke is complaining of difficulty in movement of the joints. What should the nurse do? Select all that apply. Promote exercises. Provide hand splints. Ask the patient to maintain strict bed rest. Discourage passive range of motion to avoid swelling. Tell the patient that joint immobilization is necessary after a stroke.
Promote exercises. Provide hand splints.
The nurse is caring for a patient with right-brain cerebral vascular accident (CVA). Which interventions will assist the patient in coping with perceptual deficits? Select all that apply. Provide good lighting. Break tasks into simple steps. Provide nonslip socks at all times. Allow the patient to move around in a wheelchair. Give nonverbal cues and instructions for activities.
Provide good lighting. Break tasks into simple steps. Provide nonslip socks at all times.
A patient with a hemorrhagic stroke has a decreased level of consciousness and an altered swallowing reflex. What is an appropriate nursing intervention? Providing small amounts of food Refraining from thickening agents Providing a liquid diet to the patient Evading foods or liquids that can form a bolus before swallowing
Providing small amounts of food
The patient is being transferred to a certified stroke center. What staff should be included in the care team? Select all that apply. Radiologist Neurologist Registered nurse Radiologic technician Emergency physician Patient care technician
Radiologist Neurologist Registered nurse Radiologic technician
The nurse is planning psychosocial support for the patient and family of the patient who suffered a stroke. What factor most likely will have the greatest impact on positive family coping with the situation? Specific patient neurologic deficits The patient's ability to communicate Rehabilitation potential of the patient Presence of complications of a stroke
Rehabilitation potential of the patient
What action is most beneficial to a patient with a right-brain stroke? Wear shoes when out of bed Arrange food on the left side Remove clutter and obstacles Give directions nonverbally
Remove clutter and obstacles
Question 3 While assessing a patient who sustained a hemorrhagic stroke, the nurse finds that the patient has decreased gag, cough, and swallowing reflexes. Which complication should the nurse expect in the patient? Risk of aspiration Unilateral neglect Impaired physical mobility Decreased intracranial adaptive capacity
Risk of aspiration
The nurse is caring for a patient after a stroke. Which deficit associated with the anterior cerebral artery does the nurse expect to find? Diplopia Dysphagia Rooting reflex Visual hallucination
Rooting reflex
The patient with diabetes mellitus has had a right-hemispheric stroke. Which nursing intervention should the nurse plan to provide for this patient related to expected manifestations of this stroke? Safety measures Patience with communication Mobility assistance on the right side Placing food in the left side of the patient's mouth
Safety measures
A nurse is formulating a discharge teaching plan for a patient who had a stroke 15 days ago. What instructions should the nurse include in the plan? Select all that apply. Maintain strict bed rest. Include fats in the diet. Seek spiritual assistance. Maintain adequate fluid intake. Follow-up for rehabilitation therapy is important.
Seek spiritual assistance. Maintain adequate fluid intake. Follow-up for rehabilitation therapy is important.
While doing a neurologic assessment of a patient who sustained a thrombotic stroke, the nurse records the score of a patient as 40 on a National Institutes of Health Stroke Scale (NIHSS). What does this score indicate? Minor stroke Severe stroke Moderate stroke No stroke symptoms
Severe stroke
Which sensory-perceptual deficit is associated with left-hemispheric stroke (right hemiplegia)? Overestimation of physical abilities Difficulty judging position and distance Slow and possibly fearful performance of tasks Impulsivity and impatience at performing tasks
Slow and possibly fearful performance of tasks
A nurse is planning a community-based stroke awareness/prevention health fair. Which activities would be most helpful to include? Select all that apply. Smoking cessation Cholesterol screening Blood pressure screening Early warning signs of a stroke Education on food high in vitamin K Importance of taking aspirin daily if history of sinus tachycardia
Smoking cessation Cholesterol screening Blood pressure screening Early warning signs of a stroke
A patient who had a transient ischemic attack (TIA) is being discharged home from the hospital. What patient teaching should the nurse perform before discharge? Select all that apply. Smoking cessation decreases risk of a stroke. Atrial fibrillation increases the risk of hemorrhagic stroke. Hypertension is the most important modifiable stroke risk factor. Elevated high-density lipoprotein (HDL) increases risk of stroke. If experiencing sudden muscle weakness, immediately schedule an appointment with the primary health care provider.
Smoking cessation decreases risk of a stroke. Hypertension is the most important modifiable stroke risk factor.
A patient with hemorrhagic stroke has undergone aneurysmal occlusion via clipping and has a blood pressure of 90/60 mm Hg. What should be included in postoperative care of the patient? Select all that apply. Start warfarin Start dopamine Start clopidogrel Encourage fluid intake Start crystalloid solution
Start dopamine Encourage fluid intake Start crystalloid solution
A patient was brought to the emergency department with a sudden onset of a severe headache different from any other headache previously experienced. When considering the possibility of a stroke, which type of stroke should the nurse know most likely is occurring? Embolic stroke Thrombotic stroke Subarachnoid hemorrhage Transient ischemic attack (TIA)
Subarachnoid 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? Embolic stroke Thrombotic stroke Intracerebral hemorrhage Subarachnoid hemorrhage
Subarachnoid hemorrhage
The nurse is caring for a patient who sustained a stroke and who is having difficulty swallowing. The nurse recorded the patient's swallowing status score as 4. What does this score indicate? Swallowing status is mildly compromised. Swallowing status is severely compromised. Swallowing status is moderately compromised. Swallowing status is substantially compromised.
Swallowing status is mildly compromised.
The patient was exhibiting symptoms of a stroke for two hours before the symptoms resolved. Which condition may this patient have experienced? Embolic brain stroke Acute brain infarction Transient ischemic attack Subarachnoid hemorrhage
TIA
A novice nurse is developing a care plan for impaired swallowing in a patient after a stroke. Which outcome included by the nurse requires revision? The patient is able to swallow. The patient is able to chew well. The patient is able to clear the oral cavity. The patient is able to handle oral secretions.
The patient is able to chew well.
A nurse is teaching a group of caregivers the warning signs of stroke. What type of assessment data obtained from the patients should the nurse teach the caregivers to consider as an emergency? Select all that apply. The patient is unable to sleep. The patient cannot hear properly. The patient has a loss of appetite. The patient suddenly has blurry vision. The patient suddenly has slurred speech.
The patient suddenly has blurry vision. The patient suddenly has slurred speech.
The nurse plans care for a patient who has had a stroke and is experiencing residual expressive aphasia. What is an appropriate expected outcome to be included in the plan? The patient will verbalize plans for rehabilitation. The patient will be satisfied with the care environment. The patient will demonstrate alternative communication techniques. The patient will demonstrate understanding that the aphasia is permanent.
The patient will demonstrate alternative communication techniques.
The nurse includes video games in the plan of care for a patient who sustained a stroke. What is the rationale for this intervention? The patient's anxiety can be improved. The patient's aphasia can be improved. The patient's hemiplegia can be improved. The patient's motor skills can be improved.
The patient's motor skills can be improved.
The patient is being evaluated for thrombolytic therapy. Which findings support the use of thrombolytic agents? Select all that apply. The onset of symptoms was five hours ago. The patient had a hip replacement one week ago. There has been no head trauma for three months. The patient's blood pressure (BP) is 180/100 mm Hg. There is a recent history of gastrointestinal (GI) bleeding. The computed tomographic (CT) scan is clear of hemorrhage.
There has been no head trauma for three months. The patient's blood pressure (BP) is 180/100 mm Hg. The computed tomographic (CT) scan is clear of hemorrhage.
The nurse is caring for a patient after a cerebrovascular accident. During assessment, the nurse notes adventitious breath sounds and the accumulation of sputum. Why does the nurse encourage the patient to take slow, deep breaths and to cough frequently? To prevent aspiration To prevent atelectasis To increase airway clearance To identify accumulation of secretions
To increase airway clearance
A nurse is measuring the blood pressure of a hypertensive obese patient who has been admitted to the hospital for increased blood glucose levels. While they are speaking, the nurse notes that the patient has suddenly started mumbling and is unable to articulate words. What is the nurse's priority action? Refer the patient to a speech therapist. Treat this as an emergency and call the health care provider. Ensure the patient that he or she should not worry about the illness. Ask the patient to protrude the tongue to test the hypoglossal nerve.
Treat this as an emergency and call the health care provider.
To enhance communication with a patient who has aphasia following a stroke, which communication technique is best for the nurse to use? Use mostly open-ended questions. Speak loudly while facing the patient. Use gestures or demonstrations as indicated. Finish response if patient is struggling with expressions.
Use gestures or demonstrations as indicated.
Which action will help a nurse communicate better with a stroke patient with aphasia? Utilizing touch Nod at all times Talking as if to a child Speaking loudly and firmly
Utilizing touch
A patient sustained a stroke and is experiencing cranial nerve deficits. What artery does the nurse suspect to be obstructed? Vertebral artery Middle cerebral artery Anterior cerebral artery Posterior cerebral artery
Vertebral artery
