Exam 5 Medsurg
The nurse is teaching a senior citizen's group about signs and symptoms of a stroke. Which statement by the nurse would provide accurate information?
"Call 911 immediately if a person develops slurred speech or difficulty speaking."
A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which response by the nurse is accurate?
"The obstructing plaque is surgically removed from inside an artery in the neck."
The spouse of a 67-year-old male patient with early stage Alzheimer's disease (AD) tells the nurse, "I am exhausted from worrying all the time. I don't know what to do." Which actions are best for the nurse to take next (select all that apply)?
*Offer ideas for ways to distract or redirect the patient. *Teach the spouse about adult day care as a possible respite. *Ask the spouse what she knows and has considered about dementia care options.
After receiving change-of-shift report on the following four patients, which patient should the nurse see first?
A 60-year-old patient with right-sided weakness who has an infusion of tPA prescribed
The nurse in a primary care provider's office is assessing several patients today. Which patient is most at risk for a stroke?
A 72-yr-old male patient who has hypertension and diabetes mellitus and smokes tobacco
A patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will the nurse include in the plan of care?
Apply intermittent pneumatic compression stockings
A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours. The nurse will anticipate teaching the patient about
Aspirin
A 70-year-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first?
Check the respiratory rate and effort
A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first?
Computed tomography (CT) scan
A patient who has severe Alzheimer's disease (AD) is being admitted to the hospital for surgery. Which intervention will the nurse include in the plan of care?
Maintain a consistent daily routine for the patient's care.
After change-of-shift report on the Alzheimer's disease/dementia unit, which patient will the nurse assess first?
Patient who developed a new cough after eating breakfast
Which hospitalized patient will the nurse assign to the room closest to the nurses' station?
Patient with new-onset confusion, restlessness, and irritability after surgery
When caring for a patient with a new right-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care?
Place needed objects on the patient's left side
A 71-year-old patient with Alzheimer's disease (AD) who is being admitted to a long-term care facility has had several episodes of wandering away from home. Which action will the nurse include in the plan of care?
Place the patient in a room close to the nurses' station.
Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness. Which patient problem do they determine has the highest priority for the patient?
Risk for aspiration related to inability to protect airway
A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider?
The patient has atrial fibrillation and takes warfarin (Coumadin)
A patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin?
The patient reports that symptoms began with a severe headache
A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which response by the nurse is accurate? a. "The obstructing plaque is surgically removed from an artery in the neck. "b. "The diseased portion of the artery in the brain is replaced with a synthetic graft." c. "A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed." d. "A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque."
a. "The obstructing plaque is surgically removed from an artery in the neck." -In a carotid endarterectomy, the carotid artery is incised and the plaque is removed. The response beginning, "The disease potion of the artery is replaced" describes an arterial graft procedure. The answer beginning, "A catheter with a deflated balloon is positioned at the narrow area" describes an angioplasty. The final response beginning, "A wire is threaded through the artery," describes the mechanical embolus removal in cerebral ischemia (MERCI) procedure.
After receiving change-of-shift report on the following four patients, which patient should the nurse see first? a. A 60-year-old patient with right-sided weakness who has an infusion of tPA prescribed. b. A 50-year-old patient who has A Fib and a new order of warfarin (Coumadin). c. A 40-year-old patient who experienced a TIA yesterday who has a dose of aspirin due. d. A 30-year-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine (Nimotop) scheduled.
a. A 60-year-old patient with right-sided weakness who has an infusion of tPA prescribed. -tPA needs to be infused within the first few hours after stroke symptoms start in order to be effective in minimizing brain injury. The other medications should also be given as quickly as possible, but timing of the medications is not as critical.
After receiving change-of-shift report on the following four patients, which patient should the nurse see first? a. A 60-year-old patient with right-sided weakness who has an infusion of tPA prescribed. b. A 50-year-old patient who has A Fib and a new order of warfarin (Coumadin). c. A 40-year-old patient who experienced a TIA yesterday who has a dose of aspirin due. d. A 30-year-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine (Nimotop) scheduled.
a. A 60-year-old patient with right-sided weakness who has an infusion of tPA prescribed. -tPA needs to be infused within the first few hours after stroke symptoms start in order to be effective in minimizing brain injury. The other medications should also be given as quickly as possible, but timing of the medications is not as critical.
The nurse's initial action for a patient with moderate dementia who develops increased restlessness and agitation should be to
assess for factors that might be causing discomfort.
A patient admitted with possible stroke has been aphasic for 3 hours and his current blood pressure (BP) is 174/94 mmHg. Which order by the HCP should the nurse question? a. Keep head of bed elevated to at least 30 degrees. b. Infuse normal saline intravenously at 75 mL/hr. c. Administer tissue plasminogen activator (tPA) per protocol. d. Administer a labetalol (Normodyne) drop to keep BP less than 140/90 mmHg.
d. Administer a labetalol (Normodyne) drop to keep BP less than 140/90 mmHg. -Because elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if the mean arterial pressure (MAP) is >130 mmHg or systolic pressure is >220 mmHg. Fluid intake should be 1500 to 2000 mL daily to maintain cerebral blood flow. The head of the bed should be elevated to at least 30 degrees, unless the patient has symptoms of poor perfusion. tPA may be administered if the patient meets the other criteria for tPA use.
A patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously, and health records show a history of several transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for
tissue plasminogen activator (tPA) infusion
When teaching about clopidogrel (Plavix), the nurse will tell the patient with cerebral atherosclerosis
to call the health care provider if stools are tarry
A patient complains of gas pains and abdominal distention two days after a small bowel resection. Which nursing action is best to take? a. Encourage the patient to ambulate. b. Instill a mineral oil retention enema. c. Administer the ordered IV morphine sulfate. d. Offer the ordered promethazine (Phenergan) suppository.
ANS: A Ambulation will improve peristalsis and help the patient eliminate flatus and reduce gas pain. A mineral oil retention enema is helpful for constipation with hard stool. A return-flow enema might be used to relieve persistent gas pains. Morphine will further reduce peristalsis. Promethazine (Phenergan) is used as an antiemetic rather than to decrease gas pains or distention
A 63-year-old patient who began experiencing right arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol?
Administer oxygen to keep O₂ saturation >95%Use National Institute of Health Stroke Scale to assess patientObtain CT scan without contrastInfuse tissue plasminogen activator (tPA)
While preparing a client for an upper GI endoscopy (esophagogastroduodenoscopy), the nurse should implement which interventions? Choose all that apply.
Tell the client he shouldn't eat or drink for 6 to 12 hours before the procedure. Inform the client that he will receive a sedative before the procedure.
A 40-year-old patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan? a. Apply intermittent pneumatic compression stockings. b. Assist to dangle on edge of bed and assess for dizziness. c. Encourage patient to cough and deep breathe every 4 hours .d. Insert an oropharyngeal airway to prevent airway obstruction.
a. Apply intermittent pneumatic compression stockings. -The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for VTE. Activities such as coughing and sitting up that might cause increased ICP or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate.
A 40-year-old patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan? a. Apply intermittent pneumatic compression stockings. b. Assist to dangle on edge of bed and assess for dizziness. c. Encourage patient to cough and deep breathe every 4 hours. d. Insert an oropharyngeal airway to prevent airway obstruction.
a. Apply intermittent pneumatic compression stockings. -The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for VTE. Activities such as coughing and sitting up that might cause increased ICP or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate.
A female patient who had a stroke 24 hours ago has expressive aphasia. The nurse identifies the nursing diagnosis of impaired verbal communication. An appropriate nursing intervention to help the patient communicate is to a. ask questions that the patient can answer with "yes" or "no. "b. develop a list of words that the patient can read and practice reading. c. have the patient practice her facial and tongue exercises with a mirror. d. prevent embarrassing the patient by answering for her if she does not respond.
a. ask questions that the patient can answer with "yes" or "no." -Communication will be facilitated and less frustrating to the patient when questions that require a "yes" or "no" response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by areas that control the motor aspects of speech. The nurse should allow time for the patient to respond.
A female patient who had a stroke 24 hours ago has expressive aphasia. The nurse identifies the nursing diagnosis of impaired verbal communication. An appropriate nursing intervention to help the patient communicate is to a. ask questions that the patient can answer with "yes" or "no." b. develop a list of words that the patient can read and practice reading. c. have the patient practice her facial and tongue exercises with a mirror. c. prevent embarrassing the patient by answering for her if she does not respond.
a. ask questions that the patient can answer with "yes" or "no."-Communication will be facilitated and less frustrating to the patient when questions that require a "yes" or "no" response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by areas that control the motor aspects of speech. The nurse should allow time for the patient to respond.
For a patient who had a right hemisphere stroke the nurse establishes a nursing diagnosis of a. risk for injury related to denial of deficits and impulsiveness. b. impaired physical mobility related to right-sided hemiplegia. c. impaired verbal communication related to speech-language deficits. d. ineffective coping related to depression and distress about disability.
a. risk for injury related to denial of deficits and impulsiveness. -The patient with right-sided brain damage typically denies any deficits and has poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability.
Which information about the patient who has had a subarachnoid hemorrhage is most important to communicate to the HCP? a. The patient complains of having a stiff neck. b. The patient's blood pressure is 90/50 mmHg. c. The patient reports a severe and unrelenting headache. d. The cerebrospinal fluid report shows RBC's.
b. The patient's blood pressure is 90/50 mmHg. -To prevent cerebral vasospasm and maintain cerebral perfusion, BP needs to be maintained higher than 90 mmHg systolic after a subarachnoid hemorrhage. A low BP or drop in BP indicates a need to administer fluids and/or vasopressors to increase the BP. An going headache, RBCs in the CSF, and a stiff neck are all typical clinical manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the HCP.
A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours. The nurse will anticipate teaching the patient about a. alteplase (tPA). b. aspirin (Ecotrin). c. warfarin (Coumadin). d. nimodipine (Nimotop).
b. aspirin (Ecotrin). -Following a TIA, patients typically are started on medications such as aspirin to inhibit platelet function and decrease stroke risk. tPA is used for acute ischemic stroke. Coumadin is usually used for patients with A Fib. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage.
The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to impaired self-feeding ability for a left-handed patient with left-sided hemiplegia. Which intervention should be included in the plan of care? a. Provide a wide variety of food choices. b. Provide oral care before and after meals. c. Assist the patient to eat with the right hand. d. Teach the patient the "chin-tuck" technique.
c. Assist the patient to eat with the right hand. -Because the nursing diagnosis indicates that the patient's imbalanced nutrition is related to the left-sided hemiplegia, the appropriate interventions will focus on teaching the patient to use the right hand for self-feeding. The other interventions are appropriate for patients with other etiologies for the imbalanced nutrition.
A 70-year-old female patient with a left-sided hemiparesis arrives by ambulance to the ED. Which action should the nurse take first? a. Monitor the BP. b. Send the patient for a CT scan. c. Check respiratory rate and effort. d. Assess the Glasgow Coma Scale score.
c. Check respiratory rate and effort. -The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway. The other activities should take place quickly after the ABCs are completed.
A 70-year-old female patient with a left-sided hemiparesis arrives by ambulance to the ED. Which action should the nurse take first? a. Monitor the BP .b. Send the patient for a CT scan. c. Check respiratory rate and effort. d. Assess the Glasgow Coma Scale score.
c. Check respiratory rate and effort. -The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway. The other activities should take place quickly after the ABCs are completed.
A 72-year-old patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the patient says, "I don't need the aspirin today. I don't have a fever." Which action should the nurse take? a. Document that the aspirin was refused by the patient. b. Tell the patient that the aspirin is used to prevent fever. c. Explain that the aspirin is ordered to decrease stroke risk. d. Call the HCP to clarify the medication order.
c. Explain that the aspirin is ordered to decrease stroke risk. -Aspirin is ordered to prevent stroke in patients who have experienced TIAs. Documentation of the patient's refusal to take the medication is an inadequate response by the nurse. There is no need to clarify the order with the HCP. The aspirin is not ordered to prevent aches and pains.
When caring for a patient with a new right-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care? a. Apply an eye patch to the right eye. b. Approach the patient from the right side. c. Place objects needed on the patient's left side. d. Teach the patient that the left visual deficit will resolve.
c. Place objects needed on the patient's left side. -During the acute period, the nurse should place objects on the patient's unaffected side. Because there is a visual defect in the right half of each eye, an eye patch is not appropriate. The patient should be approached from the left side. The visual deficit may not resolve, although the patient can learn to compensate for the defect.
A 68-year-old patient is being admitted with a possibles stroke. Which information from the assessment indicates that the nurse should consult with the HCP before giving the prescribed aspirin? a. The patient has dysphasia. b. The patient has atrial fibrillation. c. The patient reports that symptoms began with a severe headache. d. The patient has a history of brief episodes of right-sided hemiplegia.
c. The patient reports that symptoms began with a severe headache. -A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and TIA are not contraindications to aspirin use, so the nurse can administer the aspirin.
After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual effects, the nurse anticipates teaching the patient about a. cerebral aneurysm clipping. b. heparin IV infusion. c. oral low-dose aspirin therapy. d. tissue plasminogen activator (tPA).
c. oral low-dose aspirin therapy. -The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA.
After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual effects, the nurse anticipates teaching the patient about a. cerebral aneurysm clipping. b. heparin IV infusion. c. oral low-dose aspirin therapy. d. tissue plasminogen activator (tPA).
c. oral low-dose aspirin therapy. -The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA.
During the change of shift report a nurse is told that a patient has an occluded left posterior cerebral artery. The nurse will anticipate that the patient may have a. dysphasia. b. confusion. c. visual deficits. d. poor judgements.
c. visual deficits. -Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with middle cerebral artery involvement. Cognitive deficits and changes in judgment are more typical of anterior cerebral artery occlusion.
A 73-year-old patient with a stroke experiences facial drooping on the right side and right-sided arm and leg paralysis. When admitting the patient, which clinical manifestations will the nurse expect to find? a. Impulsive behavior. b. Right-sided neglect. c. Hyperactive left-sided tendon reflexes. d. Difficulty comprehending instructions.
d. Difficulty comprehending instructions. -Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with comprehension and use of language. The left-side reflexes are likely to be intact. Impulsive behavior and neglect are more likely with a right-sided stroke.
A patient with left-sided weakness that started 60 minutes earlier is admitted to the ED and diagnostic tests are ordered. Which test should be done first? a. CBC. b. Chest radiograph (x-ray). c. 12-lead ECG. d. Non-contrast CT scan.
d. Non-contrast CT scan. -Rapid screening with a non-contrast CT scan is needed before administration of tPA, which must be given within 4.5 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the less brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.
A patient in the ED with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the HCP? a. The patient's speech is difficult to understand. b. The patient's blood pressure is 144/90 mmHg. c. The patient takes a diuretic because of a history of hypertension. d. The patient has atrial fibrillation and takes warfarin (Coumadin).
d. The patient has atrial fibrillation and takes warfarin (Coumadin). -The use of warfarin probably contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of HTN is a risk factor for the patient but has no immediate effect on the patient's care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated.
A patient in the ED with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the HCP? a. The patient's speech is difficult to understand. b. The patient's blood pressure is 144/90 mmHg. c. The patient takes a diuretic because of a history of hypertension. d. The patient has atrial fibrillation and takes warfarin (Coumadin).
d. The patient has atrial fibrillation and takes warfarin (Coumadin). -The use of warfarin probably contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of HTN is a risk factor for the patient but has no immediate effect on the patient's care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated.
A 58-year-old patient with a left-brain stroke suddenly bursts into tears when family members visit. The nurse should a. use a calm voice to ask the patient to stop the crying behavior. b. explain to the family that depression is normal following a stroke. c. have the family members leave the patient alone for a few minutes. d. teach the family that emotional outbursts are common after strokes.
d. teach the family that emotional outbursts are common after strokes. -Patients who have left-sided brain stroke are prone to emotional outbursts that are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient's outburst suggests that depression is not the major cause of the behavior. The family should stay with the patient. The crying is not within the patient's control and asking the patient to stop will lead to embarrassment.
A 56-year-old patient arrives in the ED with hemiparesis and dysarthria that started 2 hours previously, and health records show a history of several transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for a. surgical endarterectomy. b. transluminal angioplasty. c. intravenous heparin administration. d. tissue plasminogen activator (tPA) infusion.
d. tissue plasminogen activator (tPA) infusion. -The patient's history and clinical manifestations suggest an acute ischemic stroke and a patient who is seen within 4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is having an acute ischemic stroke.
When teaching about clopidegrol (Plavix), the nurse will tell the patient with cerebral atherosclerosis a. to monitor and record the blood pressure daily. b. that Plavix will dissolve clots in the cerebral arteries. c. that Plavix will reduce cerebral artery plaque formation. d. to call the HCP if stools are blood or tarry.
d. to call the HCP if stools are blood or tarry. -Clopidegrol (Plavix) inhibits platelet function and increases the risk for gastrointestinal bleeding, so patients should be advised to notify the HCP about any signs of bleeding. The medication does not lower blood pressure, decrease plaque formation, or dissolve clots.
