Stroke

Which complication would the nurse monitor for when caring for a patient with ischemic stroke? Select all that apply. One, some, or all responses may be correct. Seizures Pneumonia Cerebral edema Hemorrhagic conversion Intracranial hypertension

Seizures Seizures are a major acute neurologic complication of ischemic stroke. Cerebral edema Cerebral edema commonly occurs after ischemic stroke and causes clinical deterioration. Hemorrhagic conversion Hemorrhagic conversion is a secondary hemorrhage at the site of the stroke lesion and is a common complication of ischemic stroke. Intracranial hypertension Uncontrolled cerebral edema can cause intracranial hypertension.

Which assessment finding would be most concerning following administration of rt-PA for treatment of an ischemic stroke? Heart rate of 102 beats/min Blood pressure of 204/98 mm Hg Temperature of 101.6°F Respiratory rate of 24 breaths/min

Blood pressure of 204/98 mm HgSignificant hypertension increases the risk of hemorrhage following rt-PA administration and would require immediate intervention.

Which intervention would the nurse plan to immediately implement when caring for a patient that reports to the emergency department with new-onset intracerebral hemorrhage? Endotracheal intubation Administration of anticoagulants Controlled hypoventilation Administration of vasopressors

Endotracheal intubation Intubation is usually necessary when caring for patients with intracerebral hemorrhage.

Which assessment finding would indicate the presence of an unruptured posterior communicating artery aneurysm? Increased temperature Irregular heart rhythm Cheyne-Stokes respirations Eyelid drooping

Eyelid drooping Ptosis (eyelid drooping) and ipsilateral pupil dilation indicate an unruptured posterior communicating artery aneurysm that is putting pressure on cranial nerve III.

Which assessment finding would indicate delayed cerebral ischemia in a patient recovering from a subarachnoid hemorrhage? Hypertension Tachycardia Altered level of consciousness Continued aphasia

Altered level of consciousness Delayed cerebral ischemia causes deterioration in the level of consciousness.

Which task would the nurse expect a patient with ischemic stroke damage to the dominant side of the brain (left) and the temporoparietal area to have difficulty with? Select all that apply. One, some, or all responses may be correct. Analytical reasoning Expression of speech Interpreting sensory information Abstract reasoning Interpreting spatial relationships

Analytical reasoning Damage to the dominant hemisphere (usually left) produces problems with analytic skills. Expression of speech Damage to the dominant hemisphere (usually left) produces problems with speech and language skills. Interpreting sensory information Damage to the temporoparietal area can create various disturbances that affect the patient's ability to interpret sensory information. Abstract reasoning Damage to the dominant hemisphere (usually left) produces problems with abstract reasoning skills.

Which approach is used to conservatively prevent the rebleeding of a subarachnoid hemorrhage (SAH)? Embolization Surgical clipping Endovascular coiling Antihypertensive medication

Antihypertensive medication Conservative measures to prevent rebleeding of a SAH include blood pressure control.

Which intervention would the nurse include in the plan of care for a patient that was admitted 6 hours ago with a stroke secondary to a ruptured aneurysm and subarachnoid hemorrhage? Apply antiembolism stockings. Suction the oropharyngeal space every 4 hours. Ambulate in the hallway three times daily. Encourage the patient to cough and breathe deeply.

Apply antiembolism stockings. Antiembolism stockings would be applied to prevent the development of venous thromboembolism.

Which medication prescription would the nurse question after administering alteplase 12 hours ago to a patient admitted to the critical care unit with ischemic stroke? Aspirin Acetaminophen Phenytoin Gabapentin

Aspirin Patients receiving fibrinolytic therapy for stroke should not receive aspirin, heparin, warfarin, ticlopidine, or any other antithrombotic or antiplatelet medications for at least 24 hours after treatment.

Which behavior is a characteristic of receptive aphasia? Unable to read words Lack of coordinated speech Inability to understand gestures Unable to communicate at any level

Unable to read words Patients with receptive aphasia cannot read words, although they can see them.

Which time frame is typically used to begin rehabilitation for a patient with a stroke? While the patient is still in the critical care setting When the patient is able to take oral food Two days prior to discharge Shortly after the risk of complications has decreased

While the patient is still in the critical care setting Rehabilitation starts in the critical care area, with a multidisciplinary team designing and implementing an individualized plan for maximizing the patient's potential for neurologic rehabilitation.

A patient who reports to the emergency department with a stiff neck, photophobia, and pain behind the eyes. In triage, the patient states, "This is the worst headache of my life." Which condition would the nurse suspect? Ischemic stroke Arteriovenous malformation Hemorrhagic stroke Subarachnoid hemorrhage

Subarachnoid hemorrhage A patient with a subarachnoid hemorrhage would have irritation of the meninges, causing a stiff neck, photophobia, and pain behind the eyes.

Which medication would be administered to control bleeding in a patient who takes warfarin and reports a spontaneous intracranial hemorrhage? Glucose Vitamin K Valproic acid Factor replacement

Vitamin K Intravenous vitamin K would be administered to patients taking a vitamin-K antagonist, such as warfarin.

Which teaching would the nurse provide to a patient scheduled for clipping of a cerebral aneurysm? "Small silicone beads are introduced into the vessel." "A device is placed over the base of the aneurysm through a craniotomy." "A device is placed inside the aneurysm to produce an endovascular thrombus." "High doses of vasoactive medications are given to increase pressure in the vessel."

"A device is placed over the base of the aneurysm through a craniotomy." During the clipping of a cerebral aneurysm, a craniotomy is done to expose and isolate the area of the aneurysm and then a clip is placed over the neck of the aneurysm to eliminate the area of weakness.

Which response would the nurse give when asked how an embolic stroke occurs? "An embolus from the heart or lower circulation lodges in a cerebral vessel." "Atherosclerotic plaque accumulates in a cerebral vessel and blocks blood flow." "The vertebral artery dissects after a chiropractic adjustment to the cervical spine." "The carotid artery bifurcation is chemically irritated and prevents the flow of blood."

"An embolus from the heart or lower circulation lodges in a cerebral vessel." An embolic stroke occurs when an embolus from the heart or lower circulation travels distally and lodges in a small vessel, obstructing the blood supply.

The nurse is educating the family of a patient admitted with acute hemorrhagic stroke due to an arteriovenous malformation. Which statement indicates understanding of the education? "He was born with the arteriovenous malformation." "His anticoagulant medications increased his risk of developing the malformation." "The vessels in his brain have too many protein deposits on them." "It's rare that this event occurred in a male."

"He was born with the arteriovenous malformation." Arteriovenous malformations are a congenital anomaly that are present from birth.

Which statement would the nurse make when asked to describe an arteriovenous malformation (AVM)? "An AVM occurs in the brainstem of people with a history of hypertension." "The blood supply is provided by cerebral arteries called feeders." "An AVM functions like a space-occupying lesion, which can be difficult to manage." "The change in the arterial wall that occurs with an AVM is caused by septic emboli that distends the vessel."

"The blood supply is provided by cerebral arteries called feeders." The pathophysiologic features of an AVM are related to the size and location of the malformation. One or more cerebral arteries, also known as feeders, supply an AVM.

In which order would the events occur during an endovascular coiling procedure? Tiny platinum coils are threaded through the microcatheter and pushed into the aneurysm. The catheter is removed from the artery. The coils conform to the shape of the aneurysm and obstruct blood flow. A thrombus forms in response to the obstructed flow, occluding the aneurysm. The catheter is advanced into the affected cerebral artery until it reaches the base of the aneurysm. A microcatheter is inserted into the femoral artery.

A microcatheter is inserted into the femoral artery. The catheter is advanced into the affected cerebral artery until it reaches the base of the aneurysm. Tiny platinum coils are threaded through the microcatheter and pushed into the aneurysm. The coils conform to the shape of the aneurysm and obstruct blood flow. A thrombus forms in response to the obstructed flow, occluding the aneurysm. The catheter is removed from the artery. Endovascular coiling involves placing one or more detachable coils into an aneurysm to produce an endovascular thrombus. A microcatheter is inserted into the femoral artery and advanced into the affected cerebral artery. Once the microcatheter is in place at the base of the aneurysm, tiny platinum coils are threaded through the microcatheter and pushed into the aneurysm. The coils conform to the shape of the aneurysm. Once the aneurysm is filled in with coils, the catheter is removed.

Which patient factor would prevent the use of alteplase as a treatment for ischemic stroke? Male sex Age 14 years NIHSS score of 15 History of breast cancer

Age 14 years Fibrinolytics would not be administered to a patient younger than 18 years of age.

Which assessment finding would indicate that the nursing interventions to prevent rebleeding are effective for a patient following surgical excision of an arteriovenous malformation? Blood pressure of 100/70 mm Hg Temperature of 99.2°F Heart rate of 58 beats/min Respiratory rate of 10 breaths/min

Blood pressure of 100/70 mm Hg To prevent rebleeding, a low blood pressure is maintained in the postoperative phase.

Which intervention would the nurse implement when caring for a patient who is experiencing vasospasm after treatment of an aneurysmal subarachnoid hemorrhage (SAH)? Administer a loop diuretic. Closely monitor for fever. Hold enteral nutrition. Encourage ambulation.

Closely monitor for fever. The nurse would monitor temperature because patients with SAH often have a fever, which is associated with worse neurologic outcomes.

For which reason would a patient recovering from a stroke benefit from speech therapy? Select all that apply. One, some, or all responses may be correct. Drooling Gurgling Pocketing food Moist voice quality Absence of a gag reflex

Drooling A speech therapist would be consulted for signs of dysphagia, such as drooling. Gurgling Signs of dysphagia, such as gurgling, would benefit from speech therapy. Pocketing food A speech therapist would be consulted for signs of dysphagia, such as pocketing food from decreased mouth movements. Moist voice quality Signs of dysphagia, such as moist voice quality, would benefit from speech therapy. Absence of a gag reflex Speech therapy would be needed for signs of dysphagia, such as the absence of a gag or cough reflex.

Which assessment finding would rule out ischemic stroke and indicate the presence of intracerebral hemorrhage (ICH)? Hypotension Mild aphasia Early loss of consciousness Gradual onset of focal defects

Early loss of consciousness Approximately 50% of patients sustain early loss of consciousness, a key feature that differentiates ICH from ischemic stroke.

Which assessment would the nurse use for limb ataxia when completing the National Institutes of Health Stroke Scale? Ask the patient to notify the examiner when a pinprick is felt. Have the patient perform the finger-nose-finger and heel-shin tests. Ask the patient to hold the leg at a 30-degree angle while supine. Have the patient raise the eyebrows, close the eyes, and show the teeth.

Have the patient perform the finger-nose-finger and heel-shin tests. To assess for limb ataxia, the patient would perform the finger-nose-finger and heel-shin tests on both sides with the eyes open.

Which complication of a stroke would the nurse suspect when a patient eats only the food that is located on the right side of the meal tray? Apraxia Agnosia Hemianopsia Prosopagnosia

Hemianopsia Visual defects restricted to a single field, right or left, are called homonymous hemianopsia. The patient eating food only from one half of the tray is a clue to hemianopsia.

Which topic would the nurse provide education about to decrease the risk of stroke from large artery atherosclerosis? Select all that apply. One, some, or all responses may be correct. Hypertension control Smoking cessation Healthy diet Glucose control Head injury prevention

Hypertension control Hypertension is a leading cause of stroke due to large artery atherosclerosis. Smoking cessation Tobacco use increases the risk of stroke from large artery atherosclerosis. Educating the patient on smoking cessation would mitigate this risk. Healthy diet Obesity increases the risk of stroke from large artery atherosclerosis. The nurse would educate the patient on healthy diet and exercise. Glucose control Diabetes increases the risk of stroke from large artery atherosclerosis, so the patient should be educated on glucose control methods.

Which intervention would the nurse incorporate into the plan of care for a patient receiving rt-PA for ischemic stroke? Administer nitroprusside for a systolic blood pressure >150 mm Hg. Maintain body temperature between 97° and 98°F. Administer prophylactic medications for cerebral edema. Implement seizure precautions.

Implement seizure precautions. Prophylactic medications would not be given for seizures, but the nurse would still implement seizure precautions.

Which intervention would the nurse recommend to a patient experiencing homonymous hemianopsia after an ischemic stroke? Approach the patient from the affected side. Instruct the patient to scan the environment. Place all food on one side of the tray. Encourage the patient to ambulate independently.

Instruct the patient to scan the environment. Many patients can learn to scan their environment visually to compensate for homonymous hemianopsia.

Match the type of aneurysm with the corresponding description. Irregular shape; involves mainly the internal carotid; > 2.5 cm wide Most common type; appears at a bifurcation of anterior circulation Rarest type; usually occurs from septic emboli that weakens vessel walls May occur during angiography or from trauma that damages the intima Saccular Dissecting Fusiform Mycotic

Irregular shape; involves mainly the internal carotid; > 2.5 cm wide - Fusiform Most common type; appears at a bifurcation of anterior circulation - Saccular Rarest type; usually occurs from septic emboli that weakens vessel walls - Mycotic May occur during angiography or from trauma that damages the intima - Dissecting

Which type of stroke is most common? Ischemic Intracerebral hemorrhage Cryptogenic Subarachnoid hemorrhage

Ischemic About 87% of strokes are ischemic strokes, making it the most common type of stroke.

Which nursing intervention would the nurse include in the plan of care for a patient with ischemic stroke who will be receiving rt-PA treatment? Select all that apply. One, some, or all responses may be correct. Place invasive lines before administering rt-PA. Hold other anticoagulants for 48 hours after administration of rt-PA. Maintain systolic blood pressure at less than 185 mm Hg. Closely monitor for signs of intracranial hemorrhage. Perform neurologic assessments every 2 hours

Place invasive lines before administering rt-PA. If possible, all invasive lines should be placed before rt-PA is administered to reduce the risk for bleeding. Maintain systolic blood pressure at less than 185 mm Hg. To prevent the incidence of hemorrhagic transformation, the systolic blood pressure should be maintained at less than 185 mm Hg. Closely monitor for signs of intracranial hemorrhage. The nurse should closely monitor for signs of intracranial hemorrhage and systemic bleeding.

Which assessment finding would indicate the development of hemiparesis in a patient admitted with stroke secondary to a subarachnoid hemorrhage? Right-sided weakness Inability to communicate Difficult swallowing Impaired sensory perception

Right-sided weakness Hemiparesis would present as unilateral weakness on one side of the entire body.