nur 116 - Davis Advantage / Edge - Stroke

The nurse is explaining to the student nurse why it is important for the post-stroke client to maintain adequate blood pressure readings. What is the nurse's best explanation? "The client is able to rest more comfortably with blood pressure values in the normal range." "When blood pressure values are too low, the kidneys have to work harder. This situation creates stress on the kidneys." "After a stroke, cerebral autoregulation may not be working properly, and this intervention helps to protect the client's brain from ischemia caused by abnormally low systemic blood pressure." "If the blood pressure values are not within normal, the client must receive more medication to control the values.

"After a stroke, cerebral autoregulation may not be working properly, and this intervention helps to protect the client's brain from ischemia caused by abnormally low systemic blood pressure."

A client who has had a stroke is upset when told he cannot eat in his room without a staff member present. What is the best explanation that the nurse can give the client regarding this information? "This is the policy and unfortunately, I must enforce this rule." "If you ask your healthcare provider to change this order, I am sure they will make an exception." "You are at risk of choking and aspirating when you eat due to your stroke." "Why do you have a problem with this rule?"

"You are at risk of choking and aspirating when you eat due to your stroke."

The nurse is completing discharge teaching with the stroke client preparing for discharge. The client asks if the healthcare provider will continue the medications prescribed pre-stroke for hypertension and high cholesterol. What is the nurse's best response to this question? -"High cholesterol and hypertension are risk factors for stroke. I would expect that the healthcare provider will continue treating these two conditions with medication after discharge." -"Because you were taking these medications and still had a stroke, I doubt the healthcare provider will continue treating these conditions." -"Ask the healthcare provider next time rounds are made. I am not able to answer that question for you." -"Let's just wait and see what is ordered when your discharge paperwork is completed by the healthcare provider. I will address your questions at that time."

-"High cholesterol and hypertension are risk factors for stroke. I would expect that the healthcare provider will continue treating these two conditions with medication after discharge."

The nurse knows that which interventions could be implemented for a stroke client at risk for aspiration? Select all that apply. -Maintain the head of the bed at least 30 degrees or greater while eating or drinking. -Ensure that the client is receiving the prescribed therapeutic food preparation. -Ensure the client is supervised while eating or drinking, observing for signs of aspiration and choking. -Advocating for evaluation of the client by a speech language pathologist. -Allow the client to watch television and visit with visitors while eating and drinking.

-Maintain the head of the bed at least 30 degrees or greater while eating or drinking. -Ensure the client is supervised while eating or drinking, observing for signs of aspiration and choking. -Advocating for evaluation of the client by a speech language pathologist.

The nurse is caring for a patient with a severe traumatic brain injury. What Glasgow Coma Score will the patient have? 15 13 9 4

4 Rationale: Severe brain injury if a score of less than or equal to GCS 8. Test Taking Tips: Understand the Glasgow Coma Scale (GCS) scoring.

The primary healthcare provider orders IV recombinant tissue plasminogen activator (rt-PA) therapy for a patient. Which is the most likely condition of the patient? Neurogenic shock Acute ischemic stroke Traumatic brain injury Increased intracranial pressure

Acute ischemic stroke Rationale: IV rt-PA therapy is used in the treatment of acute ischemic stroke. It is the only Food and Drug Administration (FDA)-approved treatment for ischemic stroke. Test Taking Tips: Understand the difference in types of neurological conditions.

The nurse notes neglect, or inattention, to one side of the body in a patient who recently had a stroke. Which describes this condition in the patient? Apraxia Agnosia Battle's sign Hemianopia

Agnosia Rationale: Weakness or paralysis of extremities may be a chronic complication of stroke. Agnosia is the term indicating that the patient has neglect or has become inattentive toward one part of the body. This condition is known as hemiparesis. Test Taking Tips: Know the terminology.

The nurse notes an ECG rhythm on the monitor that may be the cause of Tom's stroke. Which rhythm leads the nurse to believe this? Ventricular tachycardia First degree AV block Atrial fibrillation Occasional PVCs

Atrial fibrillation CORRECT. Identification of rhythm disturbances such as atrial fibrillation is essential in determining potential causes of stroke. Atrial fibrillation is an irregular rhythm where clot formation is common.

Upon assessment, the nurse notes that Tom has weakness on the right side of his body. He has vomited numerous times since admission to the emergency department, has difficulty swallowing, and is drooling saliva from the right side of his mouth. He is attempting to speak but is unable to do so. Tom is exhibiting symptoms of which syndrome? Right middle cerebral artery syndrome Basilar artery syndrome Left middle cerebral artery syndrome Non-traumatic intracerebral hemorrhage syndrome

Basilar artery syndrome CORRECT. The symptoms the client is exhibiting are signs of basilar artery syndrome. The injury to the brain may be either on the same side or opposite side of the side of the body that is displaying symptoms. Nausea and vomiting are not usually found in either left or right middle cerebral artery syndrome.

The nurse performs and assessment on a patient and discovers the finding in the image. What does it represent? Basilar skull fracture Epidural hematoma Fracture in the middle fossa Fracture in the anterior fossa

Basilar skull fracture Rationale: A late sign of a basilar fracture is bruising around the eyes (raccoon's eyes) or the ears (Battle's sign). Test Taking Tips: Understand assessment changes.

A patient has a mean arterial pressure (MAP) of 77 mm Hg. The cerebral perfusion pressure (CPP) is 61 mm Hg. What is the patient's intracranial pressure (ICP)? Record your answer using a whole number. Enter numeral only.

CPP = MAP - ICP 61 - 77 - ICP 16 = ICP Rationale: ICP is calculated by subtracting CPP from MAP. MAP - CPP = ICP. Therefore, 77 - 61 = 16 mm Hg. Test Taking Tips: Cerebral perfusion pressure is measured by subtracting intracranial pressure (ICP) from mean arterial pressure (MAP).

The nurse would expect the client admitted for a stroke to be monitored for cardiac status. Which methods would the nurse expect to see ordered for this purpose? Select all that apply. Cardiac enzymes per protocol Continuous electrocardiogram monitoring Baseline 12-lead electrocardiogram Cardiac catheterization Placement of cardiac pacemaker

Cardiac enzymes per protocol Continuous electrocardiogram monitoring Baseline 12-lead electrocardiogram

The nurse is caring for a patient with traumatic brain injury. It is noted that there is clear fluid draining from the ears. After notifying the provider, what action should the nurse take? Pack ear canal with gauze. Turn the patient onto his or her side to allow for drainage. Collect the fluid using a loosely applied gauze. Suction the fluid using a suction catheter.

Collect the fluid using a loosely applied gauze. Rationale: If clear fluid is draining from the ear or nose, it should not be stopped; it should be collected using loosely applied gauze. Test Taking Tips: Know best practice.

The nurse knows that close monitoring of serum electrolyte levels, especially sodium, is important because hyponatremia raises the risk of which stroke complication? Cumulative fluid imbalance Decreased cardiac output and arrhythmias Diabetes and liver dysfunction Acid-base imbalance and sepsis

Cumulative fluid imbalance

Tom goes for an emergency CT scan to check for intracranial hemorrhage. No intracranial hemorrhage is noted on the scan. The healthcare provider is evaluating Tom's eligibility for plasminogen activator (rt-PA) to dissolve the blood clot that is present. What would make Tom ineligible for rt-PA? He has type 2 diabetes controlled with oral agents. He has a history of a myocardial infarction (MI) 3 years ago. He has displayed stroke symptoms for 2 hours. He is taking warfarin (Coumadin) for with an INR of 2.0.

He is taking warfarin (Coumadin) for with an INR of 2.0. CORRECT. The client would not be eligible for rt-PA because of the warfarin, with an INR of 2.0. INR above 1.7 is an excluding factor for rt-PA. The combination of warfarin with the patient's INR of 2.0 and the rt-PA agent significantly increases his risk for brain hemorrhage. If the INR is 1.7 or below, the combination of warfarin and the rt-PA agent is a lower risk.

While reviewing the diagnostic test reports of a patient suspected of having a basilar skull fracture, the primary healthcare provider finds blood is collecting between the skull and the dura mater. Which is the patient most likely experiencing? Hematoma Battle's sign Fracture in the middle fossa Fracture in the anterior fossa

Hematoma Rationale: Hematoma is the condition in which blood collects in the space between the skull and the dura mater. Test Taking Tips: Recall the conditions that might lead to the collection of blood between the potential spaces of the skull and dura matter.

After an extended hospital and rehabilitation stay, Tom is ready for discharge. What discharge instructions should the nurse include for Tom and his wife? Select all that apply. Identifying the symptoms of stroke The importance of smoking cessation Encouraging the use of salt substitutes Compliance with medications Following up with healthcare provider as directed

Identifying the symptoms of stroke The importance of smoking cessation Compliance with medications Following up with healthcare provider as directed CORRECT. Discharge instructions should include education about identification of stroke symptoms, since Tom is still at risk for having another stroke. Materials on smoking cessation should be provided, along with medication compliance and follow up appointments. Salt substitutes are not recommended.

The nurse suspects lower cranial nerve dysfunction in a patient with hemorrhagic stroke. Which diagnostic characteristic supports the nurse's suspicion? Impaired swallowing Impaired family coping Impaired physical mobility Impaired verbal communication

Impaired swallowing Rationale: Impaired swallowing is related to lower cranial nerve dysfunction or decreased level of consciousness.

The nurse receives the latest laboratory report. Which finding is most concerning for Tom? Normal potassium level Low sodium level Low protein level High INR level

Low sodium level CORRECT. Close monitoring of serum electrolytes, particularly sodium, is necessary to identify disorders of salt and water imbalance resulting in hyponatremia, which places patients who have suffered a stroke at high risk for cerebral edema and neurological deterioration.

The nurse is caring for a client who is receiving anticoagulants post-stroke. The nurse would implement which precautions for clients receiving anticoagulants? Select all that apply. Monitoring for presence of bleeding Using firm bristle toothbrush for oral hygiene Implementing fall precautions Monitoring for stroke-related weakness Taking temperature via rectal route for accuracy in reading

Monitoring for presence of bleeding Implementing fall precautions Monitoring for stroke-related weakness

A patient is experiencing severe hypotension after a spinal cord injury. Which medication should the nurse anticipate will be ordered? Lorazepam Atropine Mannitol Norepinephrine

Norepinephrine Rationale: Vasoactive infusions of norepinephrine (Levophed), or phenylephrine (Neo-Synephrine) are commonly used with neurogenic shock. Test Taking Tips: Understand medications.

Tom, a 75-year-old man, was at home watching television with his wife when he began displaying strange symptoms. His wife called 911 and stated, "Something is wrong with my husband. He won't answer me when I speak to him. He is staring straight ahead and drooling from his mouth. Please send an ambulance immediately!" The ambulance arrived and transported Tom to the local emergency department. The triage nurse performs an assessment when Tom arrives. What priority nursing action should be completed? Obtain a blood pressure. Draw a serum glucose level. Obtain a sterile urine specimen. Ask the patient about his home meds.

Obtain a blood pressure. CORRECT. Of the actions listed, the nurse should quickly obtain a blood pressure. With either an ischemic or hemorrhagic stroke, close monitoring of the blood pressure is a priority to ensure that it remains within prescribed limits. The nurse would need to know the client's home medications, but not before the client has been triaged and vital signs obtained. Lab work would be drawn and glucose would be part of the metabolic panel, but this is not the priority task.

Because of Tom's current condition, what action is a priority for the nurse? Begin nutritional supplement to prevent malnutrition Position to prevent aspiration Place antithrombotic devices to prevent clots Orient to person, place, and time

Position to prevent aspiration CORRECT. After a stroke, many clients experience swallowing dysfunction, which places them at risk for aspiration and subsequent pneumonia. Tom is at especially high risk because of his vomiting.

The nurse is caring for an unconscious client after a large ischemic stroke. Which assessment changes are most concerning? Select all that apply. Rising systolic blood pressure Bradycardia Equal and reactive pupils Irregular breathing pattern Hypotension

Rising systolic blood pressure Bradycardia Irregular breathing pattern Hypotension XXXXX

Tom is admitted to the intensive care unit. The nurse receives the hand-off report from the emergency room nurse. Which priority assessments are appropriate for the nurse to perform? Select all that apply. Substance abuse assessment Serial neurological assessments every 1-2 hours Baseline neurological assessment Nutritional assessment Vital sign assessment every 1-2 hours

Serial neurological assessments every 1-2 hours Baseline neurological assessment Vital sign assessment every 1-2 hours CORRECT. Changes in level of consciousness and neurological status are early indicators of increased ICP. Neurological deterioration must be identified quickly in order to mitigate further brain injury. The nurse should obtain a baseline neurological assessment and monitor it regularly to identify change. Vital sign changes also indicate increased intracranial pressure (Cushing's Triad) and should be monitored closely.

The nurse is caring for a post-stroke client. As the client's recovery advances, what topics would the nurse include in her teaching? Select all that apply. Signs and symptoms of stroke Smoking cessation if applicable Use of salt substitutes that contain potassium Discharge medications Follow-up medical management

Signs and symptoms of stroke Smoking cessation if applicable Discharge medications Follow-up medical management

The nurse is preparing a community-based education program on risk factors for stroke. The nurse would include which modifiable risk factors in the presentation? Select all that apply. Smoking Obesity Vegetarian diet Hypercholesterolemia Advanced age

Smoking Obesity Hypercholesterolemia

The nurse is completing Tom's health history with his wife. Which of Tom's stroke risk factors are modifiable? Select all that apply. Age Smoking cigarettes Elevated cholesterol levels Race Weight

Smoking cigarettes Elevated cholesterol levels Weight CORRECT. Modifiable risk factors are risk factors that can be changed. The client could stop smoking, decrease his cholesterol level with diet, exercise, or medication, or lose weight by diet, exercise, or medication. The client cannot change his age or race.

Which type of cerebral herniation syndrome is most likely to lead to stroke in the tissue surrounding the anterior cerebral artery? Uncal herniation Central herniation Tonsillar herniation Subfalcine herniation

Subfalcine herniation Rationale: In a subfalcine herniation, brain tissue is shifted over and underneath the falx cerebri. There is risk of compression to the anterior cerebral artery, which may cause a stroke in the surrounding region of brain tissue. Test Taking Tips: Know the pathophysiology.