Stroke
A 154-pound woman has been prescribed tPA (0.9 mg/kg) for an ischemic stroke. The nurse knows to give how many mg initially? A) 6.3 mg B) 7.5 mg C) 8.3 mg D) 10 mg
6.3 mg - A person who weighs 154 lbs weighs 70 kg. To calculate total dosage, multiply 70 × 0.9 mg/kg = 63 mg. Ten percent of the calculated dose is given as an IV bolus over 1 minute. The remaining dose (90%) is given IV over 1 hour via an infusion pump. So initially the nurse gives 10% (6.3 mg) over 1 minute.
Which of the following is the most common side effect of tissue plasminogen activator (tPA)? A) headache B) bleeding C) increased ICP D) hypertension
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.
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
Cerebral aneurysm - a cerebral aneurysm is a type of hemorrhagic stroke that is characterized by an exploding headache
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
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.
A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to perform which action? A) form words that are understandable or comprehend spoken words B) speak at all C) form words that are understandable D) comprehend spoken words
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.
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) hypertension B) diabetes insipidus C) cardiac disease D) impaired cerebral circulation
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.
Which are contraindications for the administration of tissue plasminogen activator (t-PA)? Select all that apply. A) Intracranial hemorrhage B) Ischemic stroke C) Age 18 years or older D) Systolic BP less than or equal to 185 mm Hg E) Major abdominal surgery within 10 days
Intracranial hemorrhage, neoplasm, aneurysm, and major surgical procedures within 14 days are contraindications to t-PA. Clinical diagnosis of ischemic stroke, being 18 years of age or older, and a systolic BP less than or equal to 185 mm Hg are eligibility criteria.
Which is indicative of a right hemisphere stroke? A) aphasia B) spatial-perceptual deficits C) slow, cautious behavior D) altered intellectual ability
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.
When communicating with a client who has sensory (receptive) aphasia, the nurse should: A) allow time for the client to respond. B) speak loudly and articulate clearly. C) give the client a writing pad. D) use short, simple sentences.
Use short, simple sentences - Although sensory aphasia allows the client to hear words, it impairs the ability to comprehend their meaning. The nurse should use short, simple sentences to promote comprehension. Allowing time for the client to respond might be helpful but is less important than simplifying the communication. Because the client's hearing isn't affected, speaking loudly isn't necessary. A writing pad is helpful for clients with expressive, not receptive, aphasia.
A client's spouse relates how the client reported a severe headache and then was unable to talk or move their right arm and leg. After diagnostics are completed and the client is admitted to the hospital, when would basic rehabilitation begin? A) upon transfer to a rehabilitation unit B) immediately C) in 2-3 days D) after 1 week
immediately - Beginning basic rehabilitation during the acute phase is an important nursing function. Measures such as position changes and prevention of skin breakdown and contractures are essential aspects of care during the early phase of rehabilitation. The nursing goal is to prevent complications that may interfere with the client's potential to recover function.
Which of the following is the initial diagnostic in suspected stroke? A) CT with contrast B) MRI C) cerebral angiography D) noncontrast computed tomography (CT)
noncontrast computed tomography - 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.
A white female client is admitted to an acute care facility with a diagnosis of stroke. Her history reveals bronchial asthma, exogenous obesity, and iron-deficiency anemia. Which history finding is a risk factor for stroke? A) being female B) being white C) being obese D) having bronchial asthma
Being obese - Obesity is a risk factor for stroke. Other risk factors include a history of ischemic episodes, cardiovascular disease, diabetes mellitus, atherosclerosis of the cranial vessels, hypertension, polycythemia, smoking, hypercholesterolemia, hormonal contraceptive use, emotional stress, family history of stroke, and advancing age. The client's race, gender, and bronchial asthma aren't risk factors for stroke.
The nurse is caring for a client with aphasia. Which action will the nurse take when communicating with the client? Select all that apply. A) pauses between phrases B) use gestures when talking C) face the client when talking D) talk over the television volume E) speak in a normal tone of voice
Communicating with a client with aphasia can be challenging. Actions to improve communication include pausing between phrases, using gestures when talking, facing the client when talking, and speaking in a normal tone of voice. Extraneous background noise should be kept to a minimum. Turning off the sound on the television would be beneficial to improve communication.
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
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.
Which set of symptoms characterize Korsakoff syndrome? Psychosis, disorientation, delirium, insomnia, and hallucinations Severe dementia and myoclonus Tremor, rigidity, and bradykinesia Choreiform movement and dementia
Korsakoff syndrome is a personality disorder characterized by psychosis, disorientation, delirium, insomnia, and hallucinations. Creutzfeldt-Jacob disease results in severe dementia and myoclonus. The three cardinal signs of Parkinson disease are tremor, rigidity, and bradykinesia. Huntington disease results in progressive involuntary choreiform (dancelike) movements and dementia.
What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke? A) aphasia B) altered intellectual ability C) slow, cautious behavior D) L visual field deficit
L 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.
Aneurysm rebleeding occurs most frequently during which time frame after the initial hemorrhage? First 2 to 12 hours First 48 hours First week First 2 weeks
Aneurysm rebleeding occurs most frequently during the first 2 to 12 hours after the initial hemorrhage and is considered a major complication.
Which interventions would be recommended for a client with dysphagia? Select all that apply. A) Assist the client with meals. B) Allow ample time to eat. C) Test the gag reflex before offering food or fluids. D) Place food on the affected side of the mouth
A-C; 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 term refers to the failure to recognize familiar objects perceived by the senses? A) Agnosia B) Agraphia C) Apraxia D) Perseveration
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.
A nurse in a rehabilitation facility is coordinating the discharge of a client who is tetraplegic. The client, who is married and has two children in high school, is being discharged to home and will require much assistance. Who would the discharge planner recognize as being the most important member of this client's care team? A) physical therapist B) spouse C) chaplain D) home care nurse
Spouse - The client's spouse and family would need to be involved in the everyday care of the client; without their support, it is unlikely that the client would be able to manage at home.
After a stroke, a client is admitted to the facility. The client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g. Which nursing intervention is a priority for this client? Checking stools for occult blood Performing range-of-motion (ROM) exercises on the left side Keeping skin clean and dry Elevating the head of the bed to 30 degrees
Because the client's gag reflex is absent, elevating the head of the bed to 30 degrees helps minimize the client's risk of aspiration. Checking the stools, performing ROM exercises, and keeping the skin clean and dry are important, but preventing aspiration through positioning is the priority.
A female client who reports recurring headaches, accompanied by increased irritability, photophobia, and fatigue is asked to track the headache symptoms and occurrence on a calendar log. Which is the best nursing rationale for this action? Cluster headaches can cause severe debilitating pain. Migraines often coincide with menstrual cycle. Tension headaches are easier to treat. Headaches are the most common type of reported pain.
Changes in reproductive hormones as found during menstrual cycle can be a trigger for migraine headaches and may assist in the management of the symptoms. Cluster headaches can cause severe pain but are not the reason for tracking. Tension headaches can be managed but is not associated with a monthly calendar. Headaches are common but not the reason for tracking.
A diagnostic test has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include thickened liquids. Which of the following is the priority nursing diagnosis for this client? A) decreased fluid volume risk B) aspiration risk C) impaired swallowing D) malnutrition risk
Impaired swallowing - Impaired Swallowing was evident on the video fluoroscopy. Aspiration, Malnutrition, and Decreased Fluid Volume Risk can occur but are not the primary diagnosis at this point in time.
Which is a contraindication for the administration of tissue plasminogen activator (t-PA)? A) intracranial hemorrhage B) ischemic stroke C) age 18 years or older D) systolic blood pressure less than or equal to 185mmHg
Intracranial hemorrhage, neoplasm, and aneurysm are contraindications for t-PA. Clinical diagnosis of ischemic stroke, age 18 years or older, and a systolic blood pressure less than or equal to 185 mm Hg are eligibility criteria.
A client has experienced an ischemic stroke that has damaged the temporal (lateral and superior portions) lobe. Which of the following deficits would the nurse expect during assessment of this client? A) Limited attention span and forgetfulness B) Hemiplegia or hemiparesis C) Lack of deep tendon reflexes D) Auditory agnosia
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 motor neurons may cause hemiparesis, hemiplegia, and a change in reflexes.
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) "you sound stressed; maybe using some stress management techniques will help." B) "you seem upset, and it may be hard for you to focus on the teaching, I'll come back later." C) "this behavior is common in clients with stroke. Which does your spouse do more often? Laugh or cry?" D) "emotional lability is common after a stroke, and it usually improves with time."
"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.
The nurse is caring for a client following an aneurysm coiling procedure. The nurse documents that the client is experiencing Korsakoff syndrome. Which set of symptoms characterizes Korsakoff syndrome? Psychosis, disorientation, delirium, insomnia, and hallucinations Severe dementia and myoclonus Tremor, rigidity, and bradykinesia Choreiform movement and dementia
Advances in technology have led to the introduction of interventional neuroradiology for the treatment of aneurysms. Endovascular techniques may be used in selected clients to occlude the blood flow from the artery that feeds the aneurysm with coils or other techniques to occlude the aneurysm itself. Postoperative complications are rare but can occur. Potential complications include psychological symptoms such as disorientation, amnesia, and Korsakoff syndrome (disorder characterized by psychosis, disorientation, delirium, insomnia, hallucinations, and personality changes). Creutzfeldt-Jakob disease results in severe dementia and myoclonus. The three cardinal signs of Parkinson disease are tremor, rigidity, and bradykinesia. Huntington disease results in progressive involuntary choreiform (dancelike) movements and dementia.
The nurse is taking care of a client with a headache. In addition to administering medications, the nurse takes which measure to assist the client in reducing the pain associated with the headache? A) maintain hydration by drinking 8 glasses of fluid a day B) perform the Heimlich maneuver C) use pressure-relieving pads or a similar type of mattress D) apply warm or cool cloths to the forehead or back of the neck
Apply warm or cool cloths to the forehead or back of the neck - Warmth promotes vasodilation; cool stimuli reduce blood flow.
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, & profuse sweating B) hemiplegia, sz, and decreased level of consciousness C) difficulty breathing or swallowing D) tachycardia, tachypnea, and hypotension
Hemiplegia, sz, & decreased LOC - 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.
Which terms refers to blindness in the right or left half of the visual field in both eyes? A) scotoma B) diplopia C) nystagmus D) homonymous hemianopsia
Homonymous hemianopsia - Homonymous hemianopsia occurs with occipital lobe tumors. Scotoma refers to a defect in vision in a specific area in one or both eyes. Diplopia refers to double vision or the awareness of two images of the same object occurring in one or both eyes. Nystagmus refers to rhythmic, involuntary movements or oscillations of the eyes.
A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention? A) Positioning the client to prevent airway obstruction B) Keeping the client in one position to decrease bleeding C) Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess D) Maintaining the client in a quiet environment
Keeping the client in one position to decrease bleeding - The student nurse shouldn't keep the client in one position. She should carefully reposition the client often (at least every hour). The client needs to be positioned so that a patent airway can be maintained. Fluid administration must be closely monitored to prevent complications such as increased intracranial pressure. The client must be maintained in a quiet environment to decrease the risk of rebleeding.
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) L-sided cerebrovascular accident (CVA) C) R-sided cerebrovascular accident (CVA) D) completed stroke
L-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 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 & forgetfulness B) visual agnosia C) lack of deep tendon reflexes D) auditory agnosia
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.
A client has experienced an ischemic stroke that has damaged the frontal lobe of his brain. Which of the following deficits does the nurse expect to observe during assessment? A) hemiplegia or hemiparesis B) lack of deep tendon reflexes C) visual & auditory agnosia D) Limited attention span & forgetfulness
Limited attention span & forgetfulness - Damage to the frontal lobe may impair learning capacity, memory, or other higher cortical intellectual functions. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and a lack of motivation. Damage to the motor neurons may cause hemiparesis, hemiplegia, and a change in reflexes. Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia.
Which of the following is the initial diagnostic in suspected stroke? A) noncontrast computed tomography (CT) B) CT with contrast C) MRI D) cerebral angiography
Noncontrast 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.
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) remove throw rugs and electrical cords from home environment. C) use of tripod cane D) need for support group due to decreased self image related to restricted mobility
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 client on your unit is scheduled to have intracranial surgery in the morning. Which nursing intervention helps to avoid intraoperative complications, reduce cerebral edema, and prevent postoperative vomiting? A) Restrict fluids before surgery. B) Administer prescribed medications. C) Administer preoperative sedation. D) Administer an osmotic diuretic.
Restrict fluids before surgery - Before surgery, the nurse should restrict fluids to avoid intraoperative complications, reduce cerebral edema, and prevent postoperative vomiting. The nurse administers prescribed medications such as an anticonvulsant phenytoin, like Dilantin, to reduce the risk of seizures before and after surgery, an osmotic diuretic, and corticosteroids. Preoperative sedation is omitted.
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
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.
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 as soon as symptoms of the migraine begin B) take medication only when migraine is intense C) take medication just before going to bed at night D) take medication only during the morning when it's calm & quiet
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.
A patient is in the acute phase of an ischemic stroke. How long does the nurse know that this phase may last? Up to 2 weeks Up to 1 week 1 to 3 days Up to 24 hours
The acute phase of an ischemic stroke may last 1 to 3 days, but ongoing monitoring of all body systems is essential as long as the patient requires care.
When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke? A) after the patient has passed the acute phase of the stroke B) after the nurse has received the discharge orders C) the day the patient has the stroke D) the day before the patient is discharged
The day the pt has the stroke - Although rehabilitation begins on the day the patient has the stroke, the process is intensified during convalescence and requires a coordinated team effort.
An emergency department nurse is awaiting the arrival of a client with signs of an ischemic stroke that began 1 hour ago, as reported by emergency medical personnel. The treatment window for thrombolytic therapy is which of the following? A) two hours B) one hour C) six hours D) three hours
Three hours - Rapid diagnosis of stroke and initiation of thrombolytic therapy (within 3 hours) in clients with ischemic stroke leads to a decrease in the size of the stroke and an overall improvement in functional outcome after 3 months.
A 45-year-old client presents to the ED reporting trouble speaking and numbness of the right arm and leg. The nurse suspects an ischemic stroke. Which insult or abnormality can cause an ischemic stroke? A) cocaine use B) arteriovenous malformation C) trauma D) intracerebral aneurysm rupture
Cocaine use - Two classifications of ischemic strokes are cryptogenic strokes, which have no known cause, and strokes from other causes, such as illicit drug use, coagulopathies, migraine, and spontaneous dissection of the carotid or vertebral arteries. Cocaine is a potent vasoconstrictor and may result in a life-threatening reaction, even with the individual's first use of the drug. Arteriovenous malformations, trauma, and intracerebral aneurysm are associated with hemorrhagic strokes.
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 & difficulty with speech B) severe headache & early change in level of consciousness C) foot drop & external hip rotation D) confusion or change in mental status
Severe HA & early change in LOC - 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.
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) dyslipidemia B) hypertension C) smoking D) obesity
HTN - Hypertension is the most modifiable risk factor for either ischemic or hemorrhagic stroke. Unfortunately, it remains under-recognized and undertreated in most communities.
A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? A) heparin sodium B) Dexamethasone C) methyldopa D) phenytoin
Heparin sodium - Administering heparin, an anticoagulant, could increase the bleeding associated with hemorrhagic stroke. Therefore, the nurse should question this order to prevent additional hemorrhage in the brain. In a client with hemorrhagic stroke, the healthcare provider may use dexamethasone (Decadron) to decrease cerebral edema and pressure, methyldopa (Aldomet) to reduce blood pressure, and phenytoin (Dilantin) to prevent seizures.
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
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 client is brought to the emergency department in a confused state, with slurred speech, characteristics of a headache, and right facial droop. The vital signs reveal a blood pressure of 170/88 mm Hg, pulse of 92 beats/minute, and respirations at 24 breaths/minute. On which bodily system does the nurse focus the nursing assessment? A) cardiovascular system B) neurovascular system C) respiratory system D) endocrine system
Neurovascular system - The client is exhibiting signs of an evolving cerebrovascular accident, possibly hemorrhagic in nature, with neurologic complications. Nursing assessment will focus on the neurovascular system assessing level of consciousness, hand grasps, communication deficits, etc. Continual cardiovascular assessment is important but not the main focus of assessment. Respiratory compromise is not noted as a concern. The symptoms exhibited are not from an endocrine dysfunction.
A client with a cerebrovascular accident (CVA) is having difficulty with eating food on the plate. Which is the best priority nursing action to be taken? A) perform a vision field assessment. B) Reposition the tray and plate. C) Assist the client with feeding. D) Know this is a normal finding for CVA.
The nurse should perform a vision field assessment to evaluate the client for hemianopia. This finding could indicate damage to the visual area of the brain as a result of evolving CVA. Repositioning the tray and assisting with feeding would not be the best nursing action until new finding has been evaluated. Hemianopia can be associated with a CVA but, when presenting as a new finding, should be evaluated and reported immediately.
A nurse is teaching a community class that those experiencing symptoms of ischemic stroke need to enter the medical system early. The primary reason for this is which of the following? A) thrombolytic therapy has a time window of only 3 hours B) a ruptured intracranial aneurysm must quickly be repaired C) intracranial pressure is increased by a space-occupying bleed D) a ruptured arteriovenous malformation will cause deficits until it is stopped
Thrombolytic therapy has a time window of only 3 hours - Currently approved thrombolytic therapy for ischemic strokes has a treatment window of only 3 hours after the onset of symptoms. Urgency is needed on the part of the public for rapid entry into the medical system. The other three choices are related to hemorrhagic strokes.
A patient is admitted via ambulance to the emergency room of a stroke center at 1:30 p.m. with symptoms that the patient said began at 1:00 p.m. Within 1 hour, an ischemic stroke had been confirmed and the doctor ordered tPA. The nurse knows to give this drug no later than what time? A) 2:00 p.m. b) 3:00 p.m. c) 4:00 p.m. d) 7:00 p.m.
Tissue plasminogen activator (tPA) must be given within 3 hours after symptom onset. Therefore, since symptom onset was 1:00 pm, the window of opportunity ends at 4:00 pm.
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
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.
A client reports light-headedness, speech disturbance, and left-sided weakness lasting for several hours. The neurologist diagnosed a transient ischemic attack, which caused the client great concern. What would the nurse include during client education? A) When symptoms cease, the client will return to presymptomatic state. B) A TIA is an insidious, often chronic episode of neurologic impairment. C) Symptoms of a TIA may linger for up to a week. D) Two thirds of people that experience a TIA will go on to develop a stroke.
When symptoms cease, the client will return to presymptomatic state - Impaired blood circulation can be caused by arteriosclerosis, cardiac disease, or diabetes. A TIA is a sudden, brief episode of neurologic impairment. Symptoms may disappear within 1 hour; some continue for as long as 1 day. One third of people who experience a TIA subsequently develop a stroke.
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) L-sided stroke B) R-sided stroke C) cerebral aneurysm D) transient ischemic attack
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.
