Patients With Cerebrovascular Disorders
A client admitted to the emergency department is being evaluated for the possibility of a stroke. Which assessment finding would lead the nurse to suspect that the client is experiencing a hemorrhagic stroke? a. severe exploding headache b. left-sided weakness c. slurred speech d. difficulty finding appropriate words
a. severe exploding headache A hemorrhagic stroke is often characterized by a severe headache (commonly described as the "worst headache ever") or as "exploding." Weakness and speech issues are more commonly associated with an ischemic stroke.
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. Lioresal (Baclofen) 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).
Which term refers to the inability to perform previously learned purposeful motor acts on a voluntary basis? a. Agnosia b. Agraphia c. Perseveration d. Apraxia
d. Apraxia Verbal apraxia refers to difficulty forming and organizing intelligible words although the musculature is intact. Agnosia is a failure to recognize familiar objects perceived by the senses. Agraphia refers to disturbances in writing intelligible words. Perseveration is the continued and automatic repetition of an activity or word or phrase that is no longer appropriate.
Which disturbance results in loss of half of the visual field? a. Homonymous hemianopsia b. Diplopia c. Nystagmus d. Anisocoria
a. Homonymous hemianopsia Homonymous hemianopsia (loss of half of the visual field) may occur from stroke and may be temporary or permanent. Double vision is documented as diplopia. Nystagmus is ocular bobbing and may be seen in multiple sclerosis. Anisocoria is unequal pupils.
The nurse is caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke does the nurse know this client has? a. Ischemic b. Hemorrhagic c. Right-sided d. Left-sided
a. Ischemic Ischemic strokes occur when a thrombus or embolus obstructs an artery carrying blood to the brain; about 80% of strokes are the ischemic variety. The other options are incorrect.
A critical care nurse is caring for a client with a cerebrovascular accident (CVA) The client is prescribed heparin for treatment. The nurse knows to monitor the client for what adverse effects? a. Migraine attacks b. Hemorrhage c. Respiratory distress d. High blood pressure
b. Hemorrhage A client with a CVA who is given heparin should be monitored for hemorrhage and bleeding at the subcutaneous injection site. Respiratory distress, high blood pressure, or migraine attacks are not likely to occur in such a client.
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. Semi-Fowler's The head of the bed is elevated 15 to 30 degrees (semi-Fowler's position) to promote venous drainage and decrease intracranial pressure.
Which is a modifiable risk factor for transient ischemic attacks and ischemic strokes? a. Thyroid disease b. Social drinking c. Advanced age d. Smoking
d. Smoking Modifiable risk factors for TIAs and ischemic stroke include hypertension, diabetes, cardiac disease, smoking, and excessive alcohol consumption. Advanced age, gender, and race are nonmodifiable risk factors for stroke.
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. Left visual field deficit 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.
When caring for a patient who has had a hemorrhagic stroke, close monitoring of vital signs and neurological status is imperative. What is the earliest sign of deterioration in a patient with a hemorrhagic stroke? a. Headache b. Alteration in level of consciousness (LOC) c. Tonic-clonic seizures d. Shortness of breath
b. Alteration in level of consciousness (LOC) Alteration in LOC is the earliest sign of deterioration in a patient with a hemorrhagic stroke; these include mild drowsiness, slight slurring of speech, and sluggish papillary reaction.
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 Hypertension is the most modifiable risk factor for either ischemic or hemorrhagic stroke. Unfortunately, it remains under-recognized and undertreated in most communities.
A nurse is assisting with a community screening for people at high risk for stroke. To which of the following clients would the nurse pay most attention? a. A 60-year-old Black man b. A 40-year-old White woman c. A 62-year-old White woman d. A 28-year-old pregnant Black woman
a. A 60-year-old Black man The 60-year-old Black man has three risk factors: gender, age, and race. Black people have almost twice the incidence of first stroke compared with White people.
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. A thrombus formation at the site of the endarterectomy 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.
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. From the left side of the client 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.
The nurse is providing information about strokes to a community group. Which of the following would the nurse identify as the primary initial symptoms of an ischemic stroke? a. Weakness on one side of the body and difficulty with speech b. Severe headache and early change in level of consciousness c. Foot drop and external hip rotation d. Vomiting and seizures
a. Weakness on one side of the body and difficulty with speech The main presenting symptoms for an ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body; confusion or change in mental status; and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Foot drop and external hip rotation are things that can occur if a stroke victim is not turned or positioned correctly.
A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to perform which action? a. Comprehend spoken words b. Form words that are understandable c. Form words that are understandable or comprehend spoken words d. Speak at all
c. Form words that are understandable or comprehend spoken words Global aphasia is a combination of expressive and receptive aphasia and presents a tremendous challenge to the nurse to effectively communicate with the client. In receptive and expressive aphasia, the client is unable to form words that are understandable. The client who is unable to speak at all is referred to as mute.
The nurse is caring for a client with chronic migraines who is prescribed medication. What drug-related instructions should the nurse give the client? a. Take medication just before going to bed at night. b. Take medication only when migraine is intense. c. Take medication as soon as symptoms of the migraine begin. d. Take medication only during the morning when it's calm and quiet.
c. Take medication as soon as symptoms of the migraine begin. The nurse reinforces the drug therapy regimen and instructs the client on self-administration of medications. To stop the migraine headache, the nurse stresses the importance of taking medication as soon as symptoms of the migraine begin and not when the migraine intensifies.
The nurse understands the urgency of timely intervention for an ischemic stroke. Based on her knowledge of cerebral blood flow (normal CBF = 50 to 55 mL/100 g/min) and obstruction, she is aware that neurons will no longer maintain aerobic respiration at which level of CBF? a. 45 to 50 mL/100 g/min b. 35 to 45 mL/100 g/min c. 35 to 45 mL/100 g/min d. 15 to 20 mL/100 g/min
d. 15 to 20 mL/100 g/min Cerebral blood flow of less than 25 mL/100g/min is the threshold for electrical failure.
A patient has been admitted to a unit at a primary stroke center after experiencing an ischemic stroke. The nurse on the unit is aware of the vital importance of rehabilitative efforts and knows that an active rehabilitation program should begin at what point? a. As soon as the patient is able to independently identify goals for rehabilitation b. As soon as moderate motor activity is regained on the affected side c. As soon as sensory ability is regained on the affected side d. As soon as the patient regains consciousness
d. As soon as the patient regains consciousness Usually an active rehabilitation program is started as soon as the patient regains consciousness. It would be erroneous to wait until the affected side recovers. Patients may benefit from rehabilitation before they are able to independently set goals.
A patient diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse? a. Implement distraction techniques. b. Administer an analgesic. c. Inform the nurse-manager. d. Call the health care provider immediately.
d. Call the health care provider immediately. The 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 isn't necessary. Sitting with the patient is appropriate, once the health care provider has been notified of the change in the patient's condition.
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. Smoking 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.
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 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 history of atrial fibrillation has experienced a TIA. In an effort to reduce the risk of cerebrovascular accident (CVA), the nurse anticipates the priority medical treatment to include which of the following? a. Cholesterol-lowering drugs b. Anticoagulant therapy c. Monthly prothrombin levels d. Carotid endarterectomy
b. Anticoagulant therapy Anticoagulant or antiplatelet therapy can prevent clot formation associated with cardiac dysrhythmias such as atrial fibrillation. Cholesterol-lowering drugs can be ordered if indicated to manage atherosclerosis. Prothrombin and international normalized ratio (INR) levels may be ordered to monitor therapeutic effects of anticoagulant therapy. Carotid endarterectomy would be anticipated only when the carotids have narrowing from plaque.
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. Confusion c. Sudden numbness e. Visual disturbances 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.
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. Neglect of the left side This client would have deficits on the left side. Expressive aphasia typically occurs with left-hemisphere stroke.
Which is indicative of a right hemisphere stroke? a. Aphasia b. Spatial-perceptual deficits c. Slow, cautious behavior d. Altered intellectual ability
b. Spatial-perceptual deficits Clients with right hemisphere stroke exhibit partial perceptual deficits, left visual field deficit, and paralysis with weakness on the left side of the body. Left hemisphere damage causes aphasia; slow, cautious behavior; and altered intellectual ability.
A client diagnosed with a stroke is ordered to receive warfarin. Later, the nurse learns that the warfarin is contraindicated and the order is canceled. The nurse knows that the best alternative medication to give is a. dipyridamole. b. aspirin. c. clopidogrel. d. ticlopidine.
b. aspirin. If warfarin is contraindicated, aspirin is the best option, although other medications may be used if both are contraindicated.
The nurse is discharging home a patient who suffered a stroke. The patient has a flaccid right arm and leg and is experiencing problems with urinary incontinence. The nurse makes a referral to the home health nurse because the hospital nurse is aware that the most common patient response to a change in body image is what? a. Denial b. Sexual dysfunction c. Depression d. Disassociation
c. Depression Depression is a common and serious problem in stroke patients. It can result from a profound disruption in their life and changes in total function, leaving patients with a loss of independence. The nurse needs to encourage the patient to verbalize feelings to assess the effect of the stroke on self-esteem. A patient who had a stroke may be concerned about loss of sexual function. Denial and disassociation are not the most common patient responses to a change in body image.
A nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform? a. Sit with the client for a few minutes. b. Administer an analgesic. c. Inform the nurse manager. d. Call the physician immediately.
d. Call the physician immediately. The nurse should notify the physician immediately because the headache may be an indication that the aneurysm is leaking. Sitting with the client is appropriate but only after the physician has been notified of the change in the client's condition. The physician will decide whether or not administration of an analgesic is indicated. Informing the nurse manager isn't necessary.
A female patient who is recovering from a stroke has begun eating a minced and pureed diet after passing the speech pathologist's swallowing assessment. This morning, the nurse set up the patient with her breakfast tray and later noticed that the woman was swallowing her food well but dribbling small amounts of food out of affected side of her mouth. How should the nurse follow up this observation? a. Provide oral suctioning after each bite that the patient swallows. b. Make the patient NPO and encourage the care provider to consider enteral nutrition. c. Remove the patient's tray because of the risk of aspiration. d. Cue the patient to the fact that she is dribbling food while commending her for eating.
d. Cue the patient to the fact that she is dribbling food while commending her for eating. Dribbling of food should be noted and addressed but does not necessarily constitute an acute risk of aspiration. Close observation is warranted but enteral feeding and NPO status are not likely necessary. Suctioning after each bite of food is not necessary.
A client is hospitalized when presenting to the emergency department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to his presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what? a. Left-sided stroke b. Right-sided stroke c. Cerebral aneurysm d. Transient ischemic attack
d. Transient ischemic attack A transient ischemic attack (TIA) is a sudden, brief attack of neurologic impairment caused by a temporary interruption in cerebral blood flow. Symptoms may disappear within 1 hour; some continue for as long as 1 day. When the symptoms terminate, the client resumes his or her presymptomatic state. The symptoms do not describe a left- or right-sided stroke or a cerebral aneurysm.
A patient is brought to the emergency department with a possible stroke. What initial diagnostic test for a stroke, usually performed in the emergency department, would the nurse prepare the patient for? a. 12-lead electrocardiogram b. Carotid ultrasound study c. Noncontrast computed tomogram d. Transcranial Doppler flow study
c. Noncontrast computed tomogram The initial diagnostic test for a stroke is usually a noncontrast computed tomography (CT) scan. This should be performed within 25 minutes or less from the time the patient presents to the emergency department (ED) to determine if the event is ischemic or hemorrhagic (the category of stroke determines treatment).
A client has tension headaches. The nurse recommends massage as a treatment for tension headaches. How does massage help clients with tension headaches? a. Reduces hypotension b. Increases appetite c. Relaxes muscles d. Relieves migraines
c. Relaxes muscles Massaging relaxes tense muscles, causes local dilation of blood vessels, and relieves headache. However, this approach is not likely to help a client with migraine or cluster headaches. Massage is not offered to clients with tension headaches to increase their appetite or reduce hypotension.
The geriatric advanced practice nurse (APN) is doing client teaching with a client who has had a cerebrovascular accident (CVA) and the client's family. One concern the APN addresses is a potential for falls related to the CVA and resulting muscle weakness. What would be most important for the APN to include in teaching related to this concern? a. Leg exercises to strengthen muscle weakness. b. Need for support group due to decreased self image related to restricted mobility. c. Remove throw rugs and electrical cords from home environment. d. Use of tripod cane.
c. Remove throw rugs and electrical cords from home environment. Client and family teaching is essential and focuses on the following points: Remove throw rugs, clutter, and electrical cords from the client's home environment to reduce the potential for falls. Although the other interventions may be appropriate, they are not as directly related to reducing fall risk.
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. Cardiac and respiratory status 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 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. Frontal 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.
Which of the following is the initial diagnostic in suspected stroke? a. Noncontrast computed tomography (CT) b. CT with contrast c. Magnetic resonance imaging (MRI) d. Cerebral angiography
a. Noncontrast computed tomography (CT) An initial head CT scan will determine whether or not the patient is experiencing a hemorrhagic stroke. An ischemic infarction will not be readily visible on initial CT scan if it is performed within the first few hours after symptoms onset; however, evidence of bleeding will almost always be visible.
Which of the following is the chief cause of intracerebral hemorrhage (ICH)? a. Uncontrolled hypertension b. Diabetes c. Hypercholesterolemia d. Migraine headaches
a. Uncontrolled hypertension Primary intracerebral hemorrhage (ICH) from a spontaneous rupture of small arteries or arterioles accounts for approximately 80% of hemorrhagic strokes and is caused chiefly by uncontrolled hypertension. Diabetes, hypercholesterolemia, and migraine headaches are not a chief cause of ICH.
A client has experienced an ischemic stroke that has damaged the lower motor neurons of the brain. Which of the following deficits would the nurse expect during assessment? a. Limited attention span and forgetfulness b. Visual agnosia c. Lack of deep tendon reflexes d. Auditory agnosia
c. Lack of deep tendon reflexes Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia. 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 lack of motivation. Damage to the lower motor neurons may cause decreased muscle tone, flaccid muscle paralysis, and a decrease in or loss of reflexes.
Which term refers to the failure to recognize familiar objects perceived by the senses? a. Agnosia b. Agraphia c. Apraxia d. Perseveration
a. Agnosia Auditory agnosia is failure to recognize significance of sounds. Agraphia refers to disturbances in writing intelligible words. Apraxia refers to an inability to perform previously learned purposeful motor acts on a voluntary basis. Perseveration is the continued and automatic repetition of an activity, word, or phrase that is no longer appropriate.
Which interventions would be recommended for a client with dysphagia? Select all that apply. a. Assist the client with meals. b. Place food on the affected side of the mouth. c. Test the gag reflex before offering food or fluids. d. Allow ample time to eat.
a. Assist the client with meals. c. Test the gag reflex before offering food or fluids. d. Allow ample time to eat. Interventions for dysphagia include placing food on the unaffected side of the mouth, allowing ample time to eat, assisting the client with meals, and testing the client's gag reflex before offering food or fluids.
Which of the following is the most common side effect of tissue plasminogen activator (tPA)? a. Bleeding b. Headache c. Increased intracranial pressure (ICP) d. Hypertension
a. Bleeding Bleeding is the most common side effect of tPA. The patient is closely monitored for bleeding (at IV insertion sites, gums, urine/stools, and intracranially by assessing changes in level of consciousness). Headache, increased ICP, and hypertension are not side effects of tPA.
The nurse is caring for a client with aphasia. Which strategy will the nurse use to facilitate communication with the client? a. Speaking loudly b. Establishing eye contact c. Avoiding the use of hand gestures d. Speaking in complete sentences
b. Establishing eye contact The following strategies should be used by the nurse to encourage communication with a client with aphasia: face the client and establish eye contact, speak in your usual manner and tone, use short phrases, and pause between phrases to allow the client time to understand what is being said; limit conversation to practical and concrete matters; use gestures, pictures, objects, and writing; and as the client uses and handles an object, say what the object is. It helps to match the words with the object or action. Be consistent in using the same words and gestures each time you give instructions or ask a question, and keep extraneous noises and sounds to a minimum. Too much background noise can distract the client or make it difficult to sort out the message being spoken.
Which is a nonmodifiable risk factor for ischemic stroke? a. Atrial fibrillation b. Gender c. Hyperlipidemia d. Smoking
b. Gender Nonmodifiable risk factors include gender, age, and race. Modifiable risk factors include atrial fibrillation, hyperlipidemia, and smoking.
Health promotion efforts to decrease the risk for ischemic stroke involve encouraging a healthy lifestyle including a. eating fish no more than once a month. b. a low-fat, low-cholesterol diet and increased exercise. c. a high-protein diet and increased weight-bearing exercise. d. a low-cholesterol, low-protein diet and decreased aerobic exercise.
b. a low-fat, low-cholesterol diet and increased exercise. Health promotion efforts to decrease the risk for ischemic stroke involve encouraging a healthy lifestyle including a low-fat, low-cholesterol diet and increased exercise. Recent evidence suggests that eating fish two or more times per week reduces the risk of thrombotic stroke for women.
A nurse is teaching a community group about modifiable and nonmodifiable risk factors for ischemic strokes. Which of the following is a risk factor that cannot be modified? a. Hypertension b. Atrial fibrillation c. Advanced age d. Obesity
c. Advanced age Modifiable risk factors for ischemic stroke include hypertension, atrial fibrillation, hyperlipidemia, diabetes mellitus, smoking, asymptomatic carotid stenosis, obesity, and excessive alcohol consumption. Nonmodifiable risk factors include advanced age, gender, and race.
A client is experiencing dysphagia following a stroke. Which measure may be taken by the nurse to ensure that the client's diet allows for easy swallowing? a. Instruct the client to lie on the bed when eating. b. Offer liquids frequently and in large quantities. c. Help the client sit upright when eating and feed slowly. d. Allow optimum physical activity before meals to expedite digestion.
c. Help the client sit upright when eating and feed slowly. Having the client sit upright, preferably out of bed in a chair, and instructing him or her to tuck the chin toward the chest when swallowing will help prevent aspiration. The client may be started on a thick liquid or puréed diet, because these foods are easier to swallow than thin liquids. The diet may be advanced as the client becomes more proficient at swallowing. If the client cannot resume oral intake, a gastrointestinal feeding tube is placed for ongoing tube feedings and medication administration. The client should be allowed to rest before meals because fatigue may interfere with coordination and following instructions.
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. Take antihypertensive medication as ordered. 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.
An emergency department nurse is interviewing a client who is presenting with signs of an ischemic stroke that began 2 hours ago. The client reports a history of a cholecystectomy 6 weeks ago and is taking digoxin, warfarin, and labetalol. What factor poses a threat to the client for thrombolytic therapy? a. International normalized ratio greater than 2 b. Two hour time period of the stroke c. Taking digoxin d. Surgery 6 weeks ago
a. International normalized ratio greater than 2 The client is at risk for further bleeding if the international normalized ratio is greater than 2. Thrombolytic therapy must be initiated within 3 hours in clients with ischemic stroke. The client is not eligible for thrombolytic therapy if she has had surgery within 14 days. Digoxin and labetalol do not prohibit thrombolytic therapy.
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. Cerebral aneurysm A cerebral aneurysm is a type of hemorrhagic stroke that is characterized by an exploding headache.
While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are: a. Weakness on one side of the body and difficulty with speech b. Severe headache and early change in level of consciousness c. Foot drop and external hip rotation d. Confusion or change in mental status
b. Severe headache and early change in level of consciousness The main presenting symptoms for ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body, confusion or change in mental status, and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Foot drop and external hip rotation can occur if a stroke victim is not turned or positioned correctly.
An emergency department (ED) nurse has administered an ordered bolus of tissue plasminogen activator (tPA) to a male patient who was diagnosed with stroke. During the administration of tPA, the nurse should prioritize assessments related to what problem? a. Fluid overload b. Peripheral edema c. Hemorrhage d. Acute pain
c. Hemorrhage Bleeding is the most common side effect of tPA. The patient is closely monitored for bleeding (at IV insertion sites, gums, urine/stools, and intracranially by assessing changes in level of consciousness). Edema, fluid overload, and pain are not likely to result from tPA.
A client is receiving an IV infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To confirm that this drug is producing its therapeutic effect, the nurse should consider which finding most significant? a. Decreased level of consciousness (LOC) b. Elevated blood pressure c. Increased urine output d. Decreased heart rate
c. Increased urine output The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output. A decreased LOC and elevated blood pressure may indicate lack of therapeutic effectiveness. A decreased heart rate doesn't indicate that mannitol is effective.
A nurse is instructing the spouse of a client who suffered a stroke about the use of eating devices the client will be using. During the teaching, the spouse starts to cry and states, "One minute he is laughing, and the next he's crying; I just don't understand what's wrong with him." Which statement is the best response by the nurse? a. "Emotional lability is common after a stroke, and it usually improves with time." b. "You sound stressed; maybe using some stress management techniques will help." c. "You seem upset, and it may be hard for you to focus on the teaching, I'll come back later." d. "This behavior is common in clients with stroke. Which does your spouse do more often? Laugh or cry?"
a. "Emotional lability is common after a stroke, and it usually improves with time." This is the most therapeutic and informative response. Often, most relatives of clients with stroke handle the physical changes better than the emotional aspects of care. The family should be prepared to expect occasional episodes of emotional lability. The client may laugh or cry easily and may be irritable and demanding or depressed and confused. The nurse can explain to the family that the client's laughter does not necessarily connote happiness, nor does crying reflect sadness, and that emotional lability usually improves with time. The remaining responses are nontherapeutic and do not address the spouse's concerns.
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. The woman's stroke has a hemorrhagic etiology. 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 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. impaired cerebral circulation 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.
During a class on stroke, a junior nursing student asks what the clinical manifestations of stroke are. What would be the instructor's best answer? a. "Clinical manifestations of a stroke are highly variable, depending on the cardiovascular health of the client." b. "Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation." c. "Clinical manifestations of a stroke generally include aphasia, one-sided flaccidity, and trouble swallowing." d. "Clinical manifestations of a stroke depend on how quickly the clot can be dissolved."
b. "Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation." Clinical manifestations following a stroke are highly variable and depend on the area of the cerebral cortex and the affected hemisphere, the degree of blockage (total, partial), and the presence or absence of adequate collateral circulation. (Collateral circulation is circulation formed by smaller blood vessels branching off from or near larger occluded vessels.) Clinical manifestations of a stroke do not depend on the cardiovascular health of the client or how quickly the clot can be dissolved. Clinical manifestations of a stroke are not "general" but individual.
Disturbed by the high incidence and poor outcomes of stroke in the community, a public health nurse is planning a health promotion campaign that is specifically focused on stroke. Which of the following proposed outcomes would most directly address an identified public awareness need? a. "Participants will describe the factors that affect cerebral blood flow." b. "Participants will state the most common signs and symptoms of stroke." c. "Participants will state the common treatment modalities for different types of stroke." d. "Participants will describe the relationship between psychological stress and stroke."
b. "Participants will state the most common signs and symptoms of stroke." Despite the numerous national campaign efforts to increase stroke awareness over the past two decades, several studies have shown that a majority of people cannot name many of the typical stroke symptoms or do not consider calling 911 in the event they or a family member are experiencing stroke symptoms. A public health intervention addressing this knowledge deficit would be appropriate and would likely be considered more important than information pertaining to pathophysiology or treatment. Risk factors should be addressed, but stress is not central among these.
A client undergoes cerebral angiography for evaluation of a subarachnoid hemorrhage. Which findings indicate spasm or occlusion of a cerebral vessel by a clot? a. Nausea, vomiting, and profuse sweating b. Hemiplegia, seizures, and decreased level of consciousness c. Difficulty breathing or swallowing d. Tachycardia, tachypnea, and hypotension
b. Hemiplegia, seizures, and decreased level of consciousness Spasm or occlusion of a cerebral vessel by a clot causes signs and symptoms similar to those of a stroke: hemiplegia, seizures, decreased level of consciousness, aphasia, hemiparesis, and increased focal symptoms. Nausea, vomiting, and profuse sweating suggest a delayed reaction to the contrast medium used in cerebral angiography. Difficulty breathing or swallowing may signal a hematoma in the neck. Tachycardia, tachypnea, and hypotension suggest internal hemorrhage.
A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings? a. Transient ischemic attack (TIA) b. Left-sided cerebrovascular accident (CVA) c. Right-sided cerebrovascular accident (CVA) d. Completed Stroke
b. Left-sided cerebrovascular accident (CVA) When the infarct is on the left side of the brain, the symptoms are likely to be on the right, and the speech is more likely to be involved. If the MRI reveals an infarct, TIA is no longer the diagnosis. There is not enough information to determine if the stroke is still evolving or is complete.
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. cardio embolic 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.
The nurse is caring for a client diagnosed with a hemorrhagic stroke. The nurse recognizes that which intervention is most important? a. Elevating the head of the bed to 30 degrees b. Monitoring for seizure activity c. Administering a stool softener d. Maintaining a patent airway
d. Maintaining a patent airway Maintaining the airway is the most important nursing intervention. Immediate complications of a hemorrhagic stroke include cerebral hypoxia, decreased cerebral blood flow, and extension of the area of injury. Providing adequate oxygenation of blood to the brain minimizes cerebral hypoxia. Brain function depends on delivery of oxygen to the tissues. Administering supplemental oxygen and maintaining hemoglobin and hematocrit at acceptable levels will assist in maintaining tissue oxygenation. All other interventions are appropriate, but the airway takes priority. The head of the bed should be elevated to 30 degrees, monitoring the client because of the risk for seizures, and stool softeners are recommended to prevent constipation and straining, but these are not the most important interventions.
A 71-year-old man has made an appointment with his primary care provider at the urging of his wife, who states that he has occasionally had episodes of weakness and slurring of words over the past several weeks. The care provider recognizes the possibility that the man has been experiencing transient ischemic attacks (TIAs). TIAs have which of the following characteristics? a. TIAs result in motor symptoms rather than sensory symptoms. b. TIAs are a result of minor cerebral hemorrhages that spontaneously resolve. c. TIAs cause irreversible, but minor, neurological damage. d. TIAs cause symptoms that last less than 1 hour.
d. TIAs cause symptoms that last less than 1 hour. A TIA is defined as a brief episode of neurologic dysfunction caused by focal brain or retinal ischemia, with clinical symptoms typically lasting less than 1 hour, and without evidence of acute infarction. They may cause sensory symptoms and are not a result of hemorrhage.
