Stroke

A nurse is caring for an elderly client with left sided paralysis who has been a resident of a nursing home for a year after experiencing a massive stroke. The client is unable to ambulate or perform the activities of daily living without assistance. The client tells the nurse that he would like to leave the nursing home and get a small apartment. Which of the following is the most appropriate response by the nurse? -"A home care agency may be able to provide someone to assist you with daily care." -"Did something happen that made you want to leave the nursing home?" -"Can you tell me how you envision your life would change if you moved to an apartment?" -"You are unable to perform the routine tasks necessary for daily living, so that is not a real option for you now."

-"Can you tell me how you envision your life would change if you moved to an apartment?" When a client is unable to perform the activities of daily living, including grooming, bathing and toileting, meal preparation, shopping, housekeeping, or laundry, it becomes difficult to find adequate resources to allow independent living outside of a health care facility equipped with around-the-clock staff.

A nurse is caring for a client who is undergoing evaluation for fibrinolytic therapy with alteplase (Activase) for acute myocardial infarction. Which of the following statements by the client indicates a possible contraindication to therapy? -"I am short of breath and feel nauseated." -"I have had black tarry bowel movements lately." -"I take hydrochlorothiazide and captopril for my blood pressure." -"My cholesterol level is elevated, but I stopped taking my statin because of muscle pain."

-"I have had black tarry bowel movements lately." Administration of fibrinolytic therapy within 30 minutes of hospital arrival or transport to the catheterization laboratory for coronary intervention within 90 minutes are both core measures in acute myocardial infarction considered by the Joint Commission in the evaluation of an institution. the recommended total dose for alteplase is based on client weight, not to exceed 100 mg. Contraindications include: active internal bleeding, history of a recent stroke, recent (within 3 months) intracranial or intraspinal surgery or serious head trauma, presence of intracranial conditions that may increase their risk of bleeding (e.g. some neoplasms, arteriovenous malformations, or aneurysms), bleeding diathesis, and current severe uncontrolled hypertension.

A nurse is teaching the partner of a client who had a stroke about manifestations of dysphagia. Which day following statements by the client's partner indicates an understanding of the teaching? -"I will engage my partner in conversation while he is eating." -"I will monitor for a change in my partner's voice after he swallows." -"I will encourage my partner to tilt his head backward when he swallows." -"I will ensure my partner is chewing food on both sides of his mouth."

-"I will monitor for a change in my partner's voice after he swallows." The nurse should instruct the client's partner to monitor the client for manifestations of dysphagia, such as changing the quality of a client's voice after swallowing, coughing during eating, pocketing of food, drooling, or excessive tongue movement.

A nurse is caring for a client who had a stroke and required physical therapy. The client's partner appears worried and asks the nurse about the next steps in the treatment plan. Which of the following responses should the nurse give? -"We have plans to send your partner to a rehabilitation facility as soon as he is stable." -"Everyone gets worried when their partner is ill. Let's just concentrate on today." -"Don't worry. Most clients start making progress after a few days of rest." -"You will have to speak to the provider for that information. I can arrange that for you."

-"We have plans to send your partner to a rehabilitation facility as soon as he is stable." This response illustrates the therapeutic communication technique of giving information. It directly addresses the partner's concern and demonstrates that discharge and rehabilitation planning begin on admission.

The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? -"We need to discourage him from wearing eyeglasses." -"We need to place objects in his impaired field of vision." -"We need to approach him from the impaired field of vision." -"We need to remind him to turn his head to scan the last visual field."

-"We need to remind him to turn his head to scan the last visual field." Homonymous hemianopsia is loss of half of the visual field. Th client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse also should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the entire field of vision. The nurse encourages the use of personal eyeglasses if they are available.

The nurse recognizes that which patient is at greatest risk for death secondary to stroke? -A 36-year-old Caucasian male -A 45-year-old Asian male -A 56-year-old African American female -A 62-year-old Hispanic female

-A 56-year-old African American female The incidence of stroke is greater in men than women until age 55 at which time the incidence of stroke is greater in women than men. Death from stroke is greater in women and African Americans.

A nurse in the emergency department is caring for a client who has been diagnosed with an embolic stroke at their exam and non-contrast CT of the head. Which of the following medications does the nurse anticipate will be prescribed for this client? -Alteplase within 4 1/2 hours after the appearance of initial signs and symptoms -Alteplase within eight hours of the appearance of initial symptoms -Heparin to dissolve the clot and prevent future clots -Enoxaparin to dissolve the clot and prevent future clots

-Alteplase within 4 1/2 hours after the appearance of initial signs and symptoms You would expect to administer Alteplase within 3-4 1/2 hours after the appearance of initial signs and symptoms. Alteplase is a thrombolytic recombinant tissue plasminogen activator. Heparin, enoxaparin (Lovenox), and warfarin are also used in the treatment of embolic strokes; however, these medications do not dissolve clots; They only prevent future clotting.

A patient is admitted to a unit with a diagnosis of left middle cerebral artery acute ischemic stroke and is not eligible for thrombolytic therapy. The nurse recognizes that this patient is at high risk for which complication? -Delirium -Aspiration -Bronchospasm -Palpitations

-Aspiration Aspiration is the nursing priority due to swallowing difficulty after stroke. The patient may also have a weakened cough which further exacerbates the risk for aspiration.

The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully? -Gets angry with family if they interrupt the task -Experiences bouts of depression and irritability -Has difficulty with using modified feeding utensils -Consistently uses adaptive equipment in dressing self

-Consistently uses adaptive equipment in dressing self Clients are evaluated as coping successfully with lifestyle changes after a stroke if they make appropriate lifestyle alterations, use the assistance of others, and have appropriate social interactions.

A nurse is assessing a client following a stroke. Which of the following findings indicates the client is experiencing difficulty with swallowing? -Lips are dry and scaly -Coughing while eating -Enlargement of the thyroid gland -Inflammation of the gums

-Coughing while eating The client who coughed while eating might be experiencing dysphagia or difficulty with swallowing. Other assessment findings can include: change in voice tone or quality after swallowing; abnormal movement of the mouth, tongue, or lips; slow, week, imprecise, or uncoordinated speech; Abnormal gag reflex; Delayed swallowing; Incomplete oral clearance or pocketing of food; Regurgitation; Pharyngeal pooling; Delayed or absent trigger to swallow; and Inability to speak consistently.

A nurse is assessing a client with new onset of slurred speech and right sided weakness. Which of the following lab tests would the nurse expect the physician to order for evaluation of a client with suspected stroke? -Fingerstick glucose -Urine culture and sensitivity -Serum folate -Blood arsenic levels

-Fingerstick glucose initial tests include fingerstick glucose and non-contrast CT scan of the brain. Hypoglycemia must be ruled out, as it can cause stroke-like symptoms.

A nurse is providing dietary teaching to a client who has dysphagia following a stroke. Which of the following instructions should the nurse include in the teaching? -"Rest for 15 minutes prior to meals." -"Place food in the weaker side of your mouth to chew." -"Sit up in a chair for 20 minutes after eating." -Flex your head with your chin tucked down to assist with swallowing."

-Flex your head with your chin tucked down to assist with swallowing." The nurse should instruct the client to flex their head slightly forward while tucking their chin to facilitate swallowing foods and to prevent aspiration. The nurse should instruct the client to rest for 30 min prior to meals. A well rested client will have less difficulty swallowing food. The nurse should instruct the client to place food in the unaffected side of the mouth. This aids in the chewing and swallowing of food and prevents aspiration. The nurse should instruct the client to sit up for 60 min following meals to aid in the digestion of food and prevent aspiration.

A nurse is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care? (Select all that apply) -Have suction equipment available for use. -Feed the client thickened liquids. -Place food on the unaffected side of the client's mouth. -Assign an assistive personnel to feed the client slowly. -Teach the client to swallow with the neck flexed.

-Have suction equipment available for use. -Feed the client thickened liquids. -Place food on the unaffected side of the client's mouth. -Teach the client to swallow with the neck flexed. Suction equipment should be available in case of choking and aspiration. The client should be given liquids that are thicker than water to prevent aspiration. Placing food on the unaffected side of the client's mouth will allow them to have better control of the food and reduce the risk of aspiration. The client should be taught to flex the neck, tucking the chin down and under to close the epiglottis during swallowing. Due to the risk of aspiration, assistive personnel should not be assigned to feed the client because the client's swallowing ability should be assessed, and suctioning can be needed if choking occurs.

A nurse is caring for a client who had a stroke who frequently cries when family members visit. The family is upset by the crying. The nurse explains to the family members that the client is: -Having difficulty controlling emotions -Demonstrating a premorbid personality -Mourning the loss of functional abilities -Conveying unhappiness about this situation

-Having difficulty controlling emotions A common complication of a stroke is the inability to control emotional effect. Clients may be depressed or apathetic and experience lability of mood.

When caring for a client who is within 72 hours of onset of a hemorrhagic stroke, the nurse knows the client should be placed in which of the following positions? -Trendelenburg -Dorsal recumbent position -Head of the bed elevated to 30 degrees with the client's head in midline -Left lateral decubitus with the head elevated 45 degrees

-Head of the bed elevated to 30 degrees with the client's head in midline Keeping the head of the bed elevated 30 degrees with the clients head in a neutral midline position can facilitate venous drainage of blood and prevent increases in intracranial pressure during the first 72 hours after onset of hemorrhagic stroke. The head should be kept in the midline position and head and neck flexion should be avoided, since this can obstruct venous drainage. In ischemic stroke, the head of bed is initially kept flat with the head in midline neutral position to promote arterial blood flow to the brain. Hip flexion and neck flexion are avoided in both instances, as they may block venous drainage.

A nurse is caring for a client who has experienced a right-hemispheric stroke. The nurse should expect the client to have difficulty with which of the following? (Select all that apply) -Impulse control -Moving the left side -Depth perception -Speaking -Situational awareness

-Impulse control -Moving the left side -Depth perception -Situational awareness A client who has experienced a right hemispheric stroke can exhibit impulse control difficulty, such as the urgency to use the restroom; left sided hemiplegia; a loss in depth perception; aphasia; and a lack of awareness of surroundings.

A nurse is assessing a client. Which of the following findings indicates that the client has experienced a left-hemispheric stroke? -Impulse control difficulty -Poor judgment -Inability to recognize familiar objects -Loss of depth perception

-Inability to recognize familiar objects A client who experienced a left-hemispheric stroke will demonstrate the inability to recognize familiar objects, known as agnosia. Difficulty with impulse control, poor judgment, and a loss of depth perception is experienced in a client who has a right-hemispheric stroke.

A nurse is caring for a client who has been admitted after a stroke (CVA). Which of the following does the nurse understand may reflect urinary retention in this client? -Decreased urine production -Oliguria -Incontinence -Increase the blood urea nitrogen

-Incontinence After a stroke, many individuals will experience urinary retention resulting in overflow incontinence. This condition frequently improves or resolves overtime. Overflow incontinence after stroke results from damage to nerve pathways that control the coordination of muscles of the bladder and urethral sphincter.

A nurse is caring for a client who had a stroke and has difficulty using adaptive devices for eating. The nurse should initiate a referral to which of the following members of the interprofessional health care team? -Occupational therapist -Social worker -Registered dietitian -Physician assistant

-Occupational therapist And occupational therapist assists clients who have physical challenges to use adaptive devices and strategies to help with self-care activities, such as eating, bathing, dressing, and other activities of daily living. They can also help clients who have physical limitations prepare for caring for their home and family and returning to work.

A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention? -Teach the client to scan to the right to see objects on the right side of the body. -Place the bedside table on the right side of the bed. -Orient the client to the food on the plate using the clock method. -Place the wheelchair on the client's left side.

-Place the bedside table on the right side of the bed. The client is unable to visualize the left midline of their body. Placing the bedside table on the right side of the client's bed will permit visualization of items on the table. A client who has left homonymous hemianopsia has lost the left visual field of both eyes. The client should be taught to turn the head to the left to visualize the entire field of vision. Using the clock method of food placement will be ineffective because only half of the plate can be seen. The wheelchair should be placed to the client's right or unaffected side.

A nurse is caring for a client who was admitted after a right-sided CVA left them with left arm and hand weakness and slurred speech. What is the most important factor that will influence this individual's emotional response to their stroke? -Location of the lesion -Intellectual ability to understand complex health information -Quality of nursing care -Premorbid coping skills with the client

-Premorbid coping skills with the client The most important factor in an individual's response to a significant medical condition that may be life-changing are past experiences and a set of coping mechanisms developed by the client. After any major or life-changing health event or diagnosis, clients may be emotionally labile. Although emotional lability is not unusual, the eventual emotional response to a life-changing illness or injury will depend in large part on the coping mechanisms possessed by the client.

A nurse is assigned to care for a client with dementia who is admitted with a stroke. Which of the following nursing diagnosis is the highest priority when caring for this client? -Bathing/hygiene self-care deficit -Risk of injury -Impaired physical mobility -Disturbed thought processes

-Risk of injury A client with dementia is at risk of injury due to increased risk for falls. The client may not recognize her limitations, despite immobility related to the stroke.

A nurse is caring for a client who has global aphasia (both receptive and expressive). Which of the following should the nurse include into the client's plan of care? (Select all that apply) -Speak to the client at a slower rate. -Assist the client to use cards with pictures. -Speak to the client in a loud voice. -Complete sentences that the client cannot finish. -Giving instructions one step at a time.

-Speak to the client at a slower rate. -Assist the client to use cards with pictures. -Given instructions one step at a time. Clients who have global aphasia have difficulty with speaking and understanding speech. Strategies that can enhance client understanding are speaking to the client at a slower rate; the use of alternative forms of communication, such as cards with pictures or a computer; and giving instructions one step at a time. For the client who has aphasia, speaking in a loud voice is unnecessary and can be interpreted as patronizing. Allow the client adequate time to finish sentences and not complete the sentences for them.

A nurse is caring for a client who had a stroke three days ago and has developed dysphagia. The nurse should identify that a referral to which the following members of the interdisciplinary team is the priority? -Pharmacist -Occupational therapist -Dietitian -Speech therapist

-Speech therapist The greatest risk to a client who has dysphagia is aspiration due to the inability to swallow. Therefore, a speech therapist is the priority referral for this client.

An unlicensed assistive personnel (UAP) is assigned by the nurse manager to assist in moving a client with a stroke and right hemiparesis. The UAP tells the nurse manager that he doesn't remember how to use the mechanical lift. What is the appropriate response by the nurse manager? -Reprimand the nursing assistant -Teach the UAP how to use the mechanical lift -Assig the mechanical lift to another staff member -Call and report this incompetence to the supervisor

-Teach the UAP how to use the mechanical lift The nurse manager should teach the UAP how to use the mechanical lift. A reprimand is not appropriate; The UAP appropriately reported his lack of ability and this reporting is highly encouraged. Assigning the task to another team member does not solve this competency issue; education and training would solve this competency concern. It is, furthermore, not necessary to report this to the nursing supervisor because the charge nurse should be able to address the issue without the support of the supervisor.

The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? (Select all that apply) -The client is aphasic -The client has weakness on the right side of the body -The client has complete bilateral paralysis of the arms and legs -The client has weakness on the right side of the face and tongue -The client has lost the ability to move the right arm but is able to walk independently -The client has lost the ability to ambulate independently but is able to feed and bathe herself or himself without assistance

-The client is aphasic -The client has weakness on the right side of the body -The client has weakness on the right side of the face and tongue Hemiparesis is a weakness of one side of the body that may occur after a stroke. It involves weakness of the face and tongue, arm, and leg on one side. These clients are also aphasic, unable to discriminate words and letters. They are generally very cautious and get anxious when attempting a new task. Complete bilateral paralysis does not occur in hemiparesis. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating.

A nurse is caring for a client who has right sided paralysis following a stroke. Which of the following information should the nurse provide the occupational therapist who will be involved in the care of the client? -The client will need a ramp built at their home -The client is experiencing difficulty swallowing liquids -The client is right-hand dominant -The client wishes to complete an advance directive

-The client is right-hand dominant The nurse should inform the occupational therapist (OT) that the client is right hand dominant. The OT assists the client to become independent with activities of daily living, such as bathing, dressing, and grooming. A client who is right-hand dominant and is experiencing right-sided paralysis will require assistance and teaching about how to perform routine activities without the use of the dominant hand and arm.

A nurse is caring for a client who has experienced a left sided CVA. The nurse knows to intervene when the unlicensed nursing person assigned to help with feeding does which of the following? -Assist the client to sit up right at 90 degrees -Tilts the client's neck downward slightly during feeding -Thins pureed food with some milk to ease swallowing -Places food on the stronger side of the client's mouth

-Thins pureed food with some milk to ease swallowing Clients can have difficulty swallowing (dysphagia) after a cerebral vascular accident (CVA), placing them at risk of aspiration pneumonia. Measures used to modify diet and rehabilitate swallowing to reduce the risk of aspiration include: thickening liquids, positioning the client upright during feeding at a 90 degree angle, modifying food consistency to meet the client's needs (options include soft or pureed diet), tilting the client's chin downward to elevate the larynx and promote closure of the epiglottis, placing food on the side of the mouth that is stronger in order to allow the client to form a bolus for swallowing.

Select the type of stroke that is accurately paired with its etiology. -Embolic stroke: the rupture of an aneurysm -Thrombotic stroke: clotting on cerebral artery plaque -Hemorrhagic stroke: an occlusion of the cerebral artery -Cerebral stroke: the rupture of a nerve

-Thrombotic stroke: clotting on cerebral artery plaque The etiology, or cause, of a thrombotic stroke is the clotting of blood on the plaque of the cerebral artery. The occlusion of this vital artery caused by the clot can cause a thrombotic stroke. An embolic stroke occurs as the result of a clot in another part of the body that travels to and occludes the cerebral artery. A hemorrhagic stroke is caused by the rupture of an aneurysm or an artery in the brain. All of these types of strokes are cerebral strokes.

A nurse places a hand roll for a client who has paralysis of the right hand and arm after a stroke. Which best describes the purpose of a hand roll? -To increase grip strength in the hand -To promote circulation to the extremity -To prevent contracture in the hand -To support distal nerve function in the hand

-To prevent contracture in the hand Hand rolls are used to prevent contracture in clients who are not able to move their hand. The hand roll should fit into the palm of the hand. The thumb should be curved in a grasp position. A gauze strip can be looped around a hand to help keep the roll in position. Hand rolls are used to prevent the fingers from remaining in a tight fist, which can cause flexion contracture. The hand roll provides extension for the fingers.

The nurse receives a report on a patient in the ICU with an SAH and clarifies that the date of the patient's initial bleed was 4 days before. The nurse needs this information to gauge the patient's risk of which complication of SAH? -Hydrocephalus -Aspiration -Vasospasm -Myocardial ischemia

-Vasospasm Patients with subarachnoid hemorrhage are at risk for vasospasm from day 4 post-bleed through day 14 and are at peak risk for vasospasm during days 5 through 9.