Stroke and ICP

A client who has experienced an initial transient ischemic attack (TIA) states: "I'm glad it wasn't anything serious." Which is the best nursing response to this statement?

"TIA is a warning sign. Let's talk about lowering your risks."

Thrombolytic therapy should be initiated within what time frame of an ischemic stroke to achieve the best functional outcome?

3 hours

When caring for a client who has had a stroke, a priority is reduction of ICP. What client position is most consistent with this goal?

Elevation of the head of the bed

A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take?

Face the client and establish eye contact.

Which is a nonmodifiable risk factor for ischemic stroke?

Gender

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?

Hemorrhage

Which disturbance results in loss of half of the visual field?

Homonymous hemianopsia

A nurse is caring for an older client who has had a hemorrhagic stroke. The client has exhibited impulsive behavior and, despite reminders from the nurse, doesn't recognize his limitations. Which priority measure should the nurse implement to prevent injury?

Install a bed alarm to remind the client to ask for assistance and to alert staff that the client is getting out of bed.

The client has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the client's atmosphere more conducive to communication?

Provide a board of commonly used needs and phrases.

Which of the following is the chief cause of intracerebral hemorrhage (ICH)?

Uncontrolled hypertension

A client recently experienced a stroke with accompanying left-sided paralysis. His family voices concerns about how to best interact with him. They report the client doesn't seem aware of their presence when they approach him on his left side. What advice should the nurse give the family?

"The client is unaware of his left side. You should approach him on the right side."

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?

Advanced age

The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration?

Alteration in level of consciousness (LOC)

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?

Being obese

A client is brought to the emergency department with symptoms of a cerebrovascular accident (CVA). The nurse would anticipate which diagnostic evaluation to be completed prior to initiation of treatment?

Brain CT scan or MRI

A patient admitted with a stroke is coming to the unit from the emergency department. The nurse assigned to care for the new patient knows that what assessment finding is indicative of a stroke?

Difficulty speaking

A patient suffering a stroke is having a difficult time swallowing. What would the nurse document this finding as?

Dysphagia

The nurse is assessing a client with a suspected stroke. What assessment finding is most suggestive of a stroke?

Facial droop

A client with a neurological disorder has difficulty swallowing. The nurse should take special care with the client's diet because of a potential risk of imbalanced nutrition. Which measure may be taken by the nurse to ensure that the client's diet allows for easy swallowing?

Help the client sit upright when eating and feed slowly

A nurse is providing education to a community group about ischemic strokes. One group member asks if there are ways to reduce the risk for stroke. Which of the following is a risk factor that can be modified?

Hypertension

A nurse is planning discharge for a client who experienced right-sided weakness caused by a stroke. During his hospitalization, the client has been receiving physical therapy, occupational therapy, and speech therapy daily. The family voices concern about rehabilitation after discharge. How should the nurse intervene?

Inform the case manager of the family's concern and provide information about the client's current clinical status so appropriate resources can be provided after discharge.

A client with CVA is prescribed medication to treat the disorder. The client wants to know what other measures may help reduce CVA. Which is an accurate suggestion for the client?

Reduce hypertension and high blood cholesterol

When developing a care plan for a client who has recently suffered a stroke, a nurse includes the nursing diagnosis Risk for imbalanced body temperature. What is the rationale for this diagnosis?

The stroke may have impacted the body's thermoregulation centers.

A patient diagnosed with an ischemic stroke should be treated within the first 3 hours of symptom onset with which of the following?

Tissue plasminogen activator (tPA)

A patient diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for what purpose?

To prevent a stroke by removing atherosclerotic plaques blocking cerebral flow

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.

A physician orders aspirin, 325 mg P.O. daily for a client who has experienced a transient ischemic attack (TIA). The nurse should teach the client that the physician has ordered this medication to:

reduce the chance of blood clot formation.

A rehabilitation nurse caring for a client who has had a stroke is approached by the client's family and asked why the client has to do so much for herself when she is obviously struggling. What would be the nurse's best answer?

"The focus on care in a rehabilitation facility is to help the client to resume as much self-care as possible."

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 60-year-old Black man

A client with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this client?

Absolute bed rest in a quiet, nonstimulating environment

A client is following up after a visit to the emergency department where testing indicated that the client had suffered a transient ischemic attack. To prevent the occurrence of a more serious cerebrovascular accident, which lifestyle changes would the neurologist to prescribe?

Controlling hypertension, losing weight, quitting tobacco use, and anticoagulant/antiplatelet therapy are typical medical interventions prescribed to prevent stroke.