Stroke & TIA EAQ

The nurse is evaluating the collaborative care of a patient with TBI. What is the most important goal for this patient?

Achieving the highest level of functioning

The nurse is caring for four patients. Which patient does the nurse anticipate might receive fibrinolytic therapy within a 3- to 4.5-hour window as recommended by the American Stroke Association? -a patient who is 60 years old -patient who has a history of both stroke and diabetes -patient whose anticoagulation with an international normalized ratio is 1.7 or below -a patient whose baseline national institutes of health stroke scale score is over 25

-a patient who is 60 years old the american stroke association recommended an expanded time interval from 3 to 4.5 hours to administer fibrinolytic therapy for patients who are under 80 years of age

The nurse assesses a patient and notes partial hemianopia, ataxia in the right limb only, and no auditory comprehension. Pain stimulation is needed for the patient to make movements. Based on the National Institutes of Health Stroke Scale (NIHSS), what is the total score for this patient?

7 The score given for partial hemianopia is 1, and the nurse assigns a score of 2 if painful stimulation is required to make movements. The score assigned for ataxia in only the right limb is 1, and a score of 3 is given for a lack of auditory comprehension.

Which ethnic group has the highest prevalence of stroke? -asians and caucasians -hispanic men and women -African American men and women -American Indians and alaskan natives

American Indians and alaskan natives

A patient hospitalized for hypertension presses the call light and reports feeling funny. When the nurse gets to the room, the patient is slurring words and has right-sided weakness. What does the nurse do first?

Assesses ABC

A patient has been admitted to the hospital with symptoms of an embolic stroke. What etiologic factor in the patient's history places the patient at particular risk for this type of stroke?

Atrial fibrillation the source of most embolic strokes is typically the heart. emboli occur in patients with a history of trial fibrillation, ischemic heart disease, or myocardial infarction

damage to which cranial nerve would lead to facial paralysis in the patient? CN IX CN XII CN VII CN IX and X

CN VII damage to CN VII (facial nerve) would be responsible for facial paralysis.

A patient has a history of deep vein thrombosis (DVT) in the lower leg. The patient arrives at the emergency department due to fears of having a stroke. Given this history, what type of stroke might the nurse first suspect?

Embolic The patient's history of DVT leads to the nurse to consider an embolic stroke. The patient may have a recurrence of the thrombus, which has broken free and become an embolus.

a family member of a patient who experienced a stroke is anxious and says to the nurse, 'Something is the matter with grandpa. All he does is cry!' Which response by the nurse is best at this time?

He is emotionally labile and may have this behavior for some time. if the frontal love has been injured by a stroke, the patient may experience emotional liability in which the patient laughs then cries, more often for no reason. It is an uncontrollable response and should be explained to the family.

The nurse is obtaining a history on a patient who has had several transient ischemic attacks. Which risk factor in this patient's history cannot be changed with appropriate management of care? -cardiovascular disease -diabetes -head trauma -sleep apnea

Head trauma patients who have a history of head trauma have an increased risk of stroke; this risk factor does not change, even with appropriate treatment.

The nurse is teaching a patient and family about home care after a stroke. Which statement made by the patient's spouse indicates a need for further teaching?

I should spend all my time with my husband in case I'm needed family members can start to feel socially isolated when caring for a loved one. The family may need to plan for regular respite care in a structured daycare respite program or through relief provided by a friend or neighbor.

A 70 year old woman brought to the emergency department is diagnosed with acute ischemic stroke with a NIH stroke score of 20. A family member reports last seeing the patient as normal (LSN) 3.5 hours before evaluation. The patient has an INR of 1.4. The nurse anticipates that the patient will not be eligible for fibrinolytic therapy for which reason? -INR 1.4 -Female gender -Age older than 65 years -High NIH stroke scale score

INR 1.4 guidelines for tx with fibrinolytic therapy recommend administering the tx within 4.5 hours of LSN, unless the patient is over 80 years old, has a NIH stroke scale score greater than 25, or an INR less than or equal to 1.7.

A patient is brought to the emergency department with aphasia and right-sided hemiplegia. the nurse suspects a stroke in which area of the brain?

Left cerebral hemisphere

A patient is eating a soft diet while recovering from a stroke. The patient reports food accumulating in the cheek of the affected side. What is the nurse's best response?

Let's see if the speech language pathologist can help

a patient is admitted with a stroke (brain attack). Which tool does the nurse use to facilitate a focused neurologic assessment of the patient?

National institute of Health Stroke Scale (NIHSS)

A patient who sustained a transient ischemic attack is admitted to the emergency department. The nurse is teaching the student nurse about methods to prevent another TIA. Which statement made by the student nurse indicates a need for further teaching?

The patient should be placed on a liquid diet -it is not necessary for the patient to maintain a liquid diet. They can eat any food that is healthy for the heart.

The nurse is teaching the spouse and patient who has had a brain attack (CVA) about rehabilitation. Which statement by the spouse demonstrates understanding of the nurse's instruction?

The rehabilitation therapist will help identify changes needed at home.

Which statement best describes the symptoms of a transient ischemic attack (TIA)?

They resolve within 60 minutes TIA symptoms resolve within 30-60 minutes and can manifest as weakness in the arms, hands, or legs, and gait disturbance is typical.

A patient in the ED has slurred speech, confusion, and visual problems, and has been having intermittent episodes of worsening symptoms. The symptoms have a gradual onset. The patient also has a history of hypertension and atherosclerosis. What does the nurse suspect that the patient is probably experiencing?

Thrombotic stroke

Which type of stroke syndrome would most likely cause a coma in a patient?

Vertebrobasilar artery strokes occurs when blood flow through the certebrobasilar region is reduced or stopped. This may lead to coma.

which stroke syndrome includes personality and behavior changes?

anterior cerebral artery includes personality and behavior changes as well as symptoms such as bladder incontinence, aphasia and amnesia, positive grasping and sucking reflex, and memory impairment.

which patient complication is most commonly associated with dysphagia?

aspiration aspiration if a frequent complication for patients with dysphagia. Many of these aspirations are silent and are not recognized until pulmonary complications occur.

The nurse is assessing a patient admitted with a stroke. What assessment finding would indicate that the patient experienced a stroke to the right hemisphere?

denial of the illness a patient who has right sides stroke is often unaware of any deficits and may be disoriented to time and place.

Which nursing intervention takes priority in a patient with dysphagia?

keep the patient strict NPO status until he or she can swallow safely

The ER nurse is assessing a patient who presents with a stroke. The nurse finds that the patient shows perseveration, loss of deep sensation, and decreased touch sensation. What should the nurse infer from these symptoms?

the patient had a posterior cerebral artery stroke

Which symptoms can be present with a transient ischemic attack (TIA)? vertigo anosmia aphasia epistaxis blurred vision

vertigo, aphasia, blurred vision Symptoms of TIA include blurred vision, vertigo, and aphasia.

How much time will it take for the symptoms of a TIA to resolve?

30 to 60 minutes Ischemic strokes often follow warning signs such as a transient ischemic attack. Symptoms of a TIA resolve within 30 to 60 minutes.

The nurse is caring for a patient with a confirmed thrombotic stroke, whose onset of symptoms began 2 hours earlier. The nurse expects the health care provider to prescribe the administration of which drug?

rtPA dissolves the cerebral blockage, reestablishes blood flow, and prevents cerebral infarction.

which factors contraindicate administering alteplase more than three hours after stroke onset? SATA -age older than 80 years -history of both diabetes and stroke -use of warfarin or other anticoagulants -imaging evidence of middle cerebral artery involvement -NIHSS score less than 25

-age older than 80 years -history of both diabetes and stroke -use of warfarin or other anticoagulants -imaging evidence of middle cerebral artery involvement

The nurse receives a patient in the emergency department who experienced a stroke. The patient is alert and requests something to eat from the nurse. Which is the best action the nurse can take? -provide thickened fluids to the patient -assess the swallowing ability of the patient -obtain a prescription to give IV fluids -assess the level of consciousness in the patient

-assess the swallowing ability of the patient

The nurse is providing discharge teaching to a patient who had a carotid stent placement. The nurse instructs the patient to contact the health care provider at the occurrence of which symptoms? -headache -weight gain -constipation -neck swelling -severe neck pain -muscle weakness

-headache -neck swelling -severe neck pain -muscle weakness

Which type of stroke shows interrupted vessel integrity and bleeding that occurs into the brain tissue or into the subarachnoid space? -embolic stroke -ischemic stroke -thrombotic stroke -hemorrhagic stroke

-hemorrhagic stroke in hemorrhagic stroke, vessel integrity is interrupted and bleeding occurs into the brain tissue or into the subarachnoid space.

The nurse is teaching a group of older adults about TIA. Which statement made by a participant indicates a need for further teaching regarding TIAs? -there is a loss of central vision -symptoms last less than 24 hours -a TIA is a warning sign for ischemic stroke -a TIA of any kind is a medical emergency

-there is a loss of central vision A TIA leads to loss of peripheral vision, not central vision. This results in tunnel vision.

Alteplase should be given within how many hours from the onset of symptoms of stroke?

4.5 the most important factor in whether or not to give alteplase is the time between symptom onset and time seen in the stroke center. The american stroke association recommends fibrinolytic therapy started within 4.5 hours of symptom onset for most patients.

During assessment, the nurse notes that a patient cannot identify the month, cannot state his or her age correctly, the arm and leg drift when elevated, and that the patient is silent when asked to identify common items. The nurse should document what total score in the patient's medical record based on the National Institutes of Health Stroke Scale (NIHSS)

6 A patient who is unable to name the month or state his or her current age is assigned a score of 2. Drifting of the arm and leg when elevated is assigned a score of 1. A score of 3 is given for an inability to name common objects. The total score for this patient is 6.

a patient weighing 165 pounds will begin receiving rtPA to treat an ischemic stroke. The nurse expects an order to administer how many milligrams of rtPA in the first minute of the infusion?

6.75 mg

Which are risk factors for stroke? Select all that apply. A. High blood pressure B.Previous stroke or transient ischemic attack (TIA) C. Smoking D. Use of oral contraceptives E. Female gender

A. High blood pressure B.Previous stroke or transient ischemic attack (TIA) C. Smoking D. Use of oral contraceptives Common modifiable risk factors for developing a stroke include smoking and the use of oral contraceptives, specifically in women over the age of 35 and in women over the age of 30 who smoke. Other risk factors include high blood pressure and history of a previous TIA.

A patient has experienced a right-hemisphere stroke. What is an important nursing action while caring for this patient?

stand on the patient's left side when talking to increase the visual field patient with right sided involvement often have an inability to recognize physical impairment and will exhibit neglect of the left visual field

Which group is at the highest risk for stroke? -white men -latino men -black women -alaskan native men

Alaskan native men Alaskan native and american indian patients are at the highest risk for stroke

Which drug is considered an anti thrombotic? warfarin heparin clopidogrel nimlodipine

Clopidogrel clopidogrel is considered an anti thrombotic. It helps prevent the formation of future clots. Warfarin and heparin are anticoagulants, which work in a different fashion than clopidogrel.

Which initial site is the most common source of emboli for those experiencing embolic stroke?

Heart embolic strokes are caused by a thrombus or group of thrombi break off from one area of the body and travel to the cerebral arteries via the carotid artery or vertebrobasilar system

The laboratory results for a patient who sustained a stroke shows the presence of proteins in the cerebrospinal fluid. What should the nurse infer from the reports?

The patient had a thrombotic stroke the presence in the CSF is indicative of a thrombotic stroke.

A patient who has experienced symptoms consistent with a transient ischemic attack refuses to go to the emergency department because the symptoms resolved at home. Which statement would the clinic nurse make over the phone to convince the patient to seek care?

Your condition could progress to a stroke a single TIA indicates a high risk for stroke.

A patient with an acute ischemic stroke is admitted to the emergency department. The nurse is teaching a student nurse about potential medications the patient may need. Which statement made by the student nurse shows ineffective learning?

a programmable pump should be used to deliver an initial dose of 120 mg over 2 hours with 10% of the dose given intravenously Alteplase is the only drug that is approved for the treatment of acute ischemic stroke. The maximum initial dose to deliver through a programmable pump is 90mg over 60 minutes with 10% of the dose given intravenously.

Nursing actions to help prevent increased intracranial pressure after a stroke include which activity?

careful monitoring of temperature patients who have had a stroke are at increased risk of ICP for 24-48 hours after the stroke. The nurse should carefully monitor temperature since a temp elevation can increase the risk

A patient recovering from a stroke reports double vision that is preventing the patient from effectively completing activities of daily living. How does the nurse help the patient compensate?

covers the affected eye

A patient diagnosed with a stroke is receiving recombinant tissue plasminogen activator (rtPA) through one intravenous line. The nurse discovers that the second line has infiltrated and removes it. The insertion site continues bleed even after the nurse applies pressure on it. What is the priority nursing action?

discontinue the rtPA infusion rtPA is a fibrinolytic agent used for the treatment of ischemic or embolic stroke. Bleeding is a side effect of this medication caused by its pharmacotherpeutic action. Therefore, if the nurse observes any bleeding that is not easily controlled, then the rtPA infusion should be stopped immediately to prevent complications.

A patient is receiving rtPA for an acute ischemic stroke. What nursing intervention does the nurse perform first to properly take care of the patient?

ensure that the prescribed follow-up computed tomography (CT) scan is done after treatment is completed and before starting anti platelet drugs.

A patient experienced a stroke that caused damage to Broca's area. The nurse expects the patient to experience what phenomenon as a result of this injury?

expressive aphasia it is a motor speech problem in which the patient generally understands what is being said but cannot communicate verbally. Writing skills are also affected.

the nurse is doing a neurological assessment on a patient admitted to the emergency department. The patient reports having had a slight headache, speech deficits, confusion, and blurred vision. What does the nurse suspect is happening to the patient?

formation of a blood clot a blood clot can lead to a thrombotic stroke, which causes a slight headache, speech deficits, confusion, and blurred vision.

Which action by unlicensed assistive personnel in caring for a patient after a stroke requires immediate intervention by the nurse?

gently pulling on a patients flaccid arm to assist the patient up in bed

The daughter of a patient who has had a stroke asks the nurse for additional resources. What is the nurse's best response?

go to the National Stroke Association website.

Which type of stroke is caused by an aneurysm or hypertension? embolic ischemic thrombotic hemorrhagic

hemorrhagic stroke vessel integrity is interrupted and bleeding occurs into the brain tissue or into the subarachnoid space due to aneurysm or hypertension

which potential disorder should be ruled out before a patient's level of consciousness is attributed to stroke?

hypoglycemia can present as a decreased level of alertness/consciousness

The patient is admitted with a diagnosis of stroke in the right cerebral hemisphere. Upon assessment, which primary deficit does the nurse expect to find?

impaired proprioception strokes in right hemisphere affect proprioception, visual, and spatial awareness. The patient may also be disoriented to place and time.

A patient is brought to the emergency department (ED) with sudden onset of right-sided paralysis and difficulty speaking. A family member is worried that these symptoms will be permanent. Based on the patient's symptoms, the nurse anticipates which outcome?

improvement over several days embolic strokes have a sudden onset of symptoms that include paralysis and expressive aphasia and tend to resolve over hours to days.

A patient has been admitted with a diagnosis of a stroke (brain attack). The nurse suspects that the patient has had a right hemisphere stroke because the patient exhibits which symptoms?

impulsiveness and smiling

A patient is admitted to the ER for a stroke. Which intervention helps provide proper care for the patient?

maintain the head of the patient in a midline, neutral position

Which substances does brain functioning require continuously because the brain does not have the ability to store them? SATA -oxygen -sodium -glucose -serotonin -potassium -acetylcholine

oxygen and glucose the brain cannot store oxygen or glucose; therefore it must receive a constant flow of blood to provide these substances to maintain normal function.

A patient is having difficulty understanding spoken and written words and is saying made up words and meaningless speech. what would be the possible reason behind the patient's condition?

receptive aphasia occurs due to injury in wernicke's area in the the temporoparietal area. This leads to the patient having difficulty understanding spoken and written words, creating made-up words, and using meaningless speech

A patient is receiving IV administration of rtPA therapy. Which sign/symptom alerts the nurse that the infusion should be discontinued?

report of a headache the nurse should discontinue the therapy and notify the health care provider if severe headache or hypertension, bleeding, nausea, and/or vomiting occur.

What type of complication would a patient with the condition depicted in the image be at risk for developing?

subarachnoid hemorrhage the image shows an unusual link up of arteries and veins. This condition is called an arteriovenous malformation which results in bleeding into the subarachnoid space leading to subarachnoid hemorrhage.

The nurse is caring for a patient one day after the patient experienced a stroke. The patient is fully alert and has weakness of the right side of the body. Which assessment finding indicates an increasing intracranial pressure?

the patient is no longer oriented to place