Stroke Management
A relative of a stroke pt who is unable to walk is not sure about the benefits of mirror therapy. How will the nurse assure the relative?
-"mirror therapy may improve the pt's ability to walk." -"Mirror therapy is an additional intervention along with other treatments."
A pt who has had a stroke is frustrated by mobility problems. What should the nurse do?
-Allow family and friends to visit the patient more often -Speak to the pt in a calm, caring manner to reduce frustration -help the family understand that frustration is common in the first year after a stroke.
What aspects of the medical history of a female pt who has had a stroke could be associated with the event?
-Current use of high-dose oral contraceptives -history of migraine headaches with aura
What should be included in the nursing plan for prevention of skin breakdown in a stroke pt?
-Good skin hygiene -Applying emollients to dry skin
A patient with a history of transient ischemic attack has been prescribed aspirin at a dose of 81 mg/day. What information about aspirin should be given to the patient?
-It may cause tinnitus, which should be reported immediately -it may cause bleeding, which should be reported immediately.
A nurse is caring for a pt who has aphasia after suffering from a stroke. How will the nurse communicate with the pt?
-Make use of gestures -present only one thought at a time -Do not interrupt the pt if he or she is taking too long to communicate
A nurse is delegating responsibilities to unlicensed assistive personnel for caring for a pt who has suffered from a stroke this morning. What responsibilities will the nurse assign?
-Measure and record urine output -perform passive and active range-of-motion exercises
A patient has been given an intraarterial infusion of tissue plasminogen activator (tPA) for ischemic stroke. What are the responsibilities of the nurse for 24 hours post treatment?
-Monitor vital signs -check BP
A nurse is caring for a patient who had a stroke and is at risk of venous thromboembolism (VTE). What should be included in the nursing interventions for such patients?
-Note unusual warmth of the legs -measure the calf and thigh daily -observe swelling of lower extremities
A patient suffered a stroke one day ago. Which aspects of care may only be performed by the registered nurse caring for this patient?
-assess neurologic status -assess respiratory status
A pt who had a stroke three days ago has constipation. What should be the first interventions?
-encourage physical activity -encourage fluid and fiber intake
A patient who has been diagnosed with stroke is complaining of difficulty in movement of the joints. What should the nurse do?
-promote exercises -provide hand splints
The nurse is caring for a pt with right-brain cerebral vascular accident (CVA). What interventions will assist the pt in coping with perceptual deficits?
-provide good lighting -break tasks into simple steps -provide nonslip socks at all times
A pt with a known history of hypertension presents to the ED with the complaint of sudden severe headache with no known cause. What should the nurse do first?
Obtain a computed tomographic (CT) scan
The nurse uses appropriate delegation of assignments when instructing the experienced unlicensed assistive personnel (UAP) to do what?
Perform passive range of motion (PROM) to flaccid extremities (after appropriate training and evaluation the UAP can perform PROM to pts who have had a stroke)
A pt presents to the ED reporting a sudden onset of headache described as "the worse headache ever." The pt also reports nausea and visual disturbances. What collaborative intervention is a priority for the nurse?
Prepare pt for transport to a CT scan.
A patient with a hemorrhagic stroke has a decreased level of consciousness and an altered swallowing reflex. What is an appropriate nursing intervention?
Providing small amounts of food
The nurse is planning psychosocial support for the pt and family of the pt who suffered a stroke. What factor most likely will have the greatest impact on positive family coping with the situation?
Rehabilitation potential of the pt
The nurse includes video games in the plan of care for a patient who sustained a stroke. What is the rationale for this intervention?
The patient's motor skill can be improved.
A novice nurse is developing a care plan for impaired swallowing in a pt after a stroke. What outcome included by the nurse requires revision?
The pt is able to chew well (swallowing does not involve increasing the chewing ability)
The nurse plans care for a pt who has had a stroke and is experiencing residual expressive aphasia. What is an appropriate expected outcome to be included in the plan?
The pt will demonstrate alternative communication techniques
A patient underwent aneurysm clipping six hours ago for subarachnoid hemorrhage and is being treated with nimodipine. While examining the patient, the nurse finds that the pulse of the patient is 50 beats per minute (beats/minute) and the blood pressure is 90/60 mm Hg. What should the nurse do?
Hold the medication and contact the primary health care provider
A patient is scheduled for a serial computed tomography (CT) scan after a stroke. What should the nurse tell the patient and the patient's relatives about this procedure?
It helps to evaluate recovery. It helps to assess the effectiveness of treatment.
During the acute phase of stroke management, the most important nursing intervention to decrease risk of aspiration is what?
Maintaining nothing by mouth (NPO) status.
A computed tomography (CT) scan of the head of a pt reveals that the pt has experienced a hemorrhagic stroke. What is the priority nursing invention in the ED?
Maintenance of the pt's airway
A nurse is preparing a menu for a stroke pt with dysphagia. What food should be included in the diet?
Mashed potatoes (scrambled eggs as well)
The nurse is developing a plan of care for a pt with an acute ischemic stroke in the first 48 hours after admission. What activity can the nurse delegate to the unlicensed assistive personnel (UAP)?
Measuring the urine output
A nurse is measuring the BP of a hypertensive obese pt who has been admitted to the hospital for increased blood glucose levels. While they are speaking, the nurse notes that the pt has suddenly started mumbling and is unable to articulate words. What is the nurse's priority action?
Treat this as an emergency and call the health care provider
To enhance communication with a pt who has aphasia following stroke, what communication technique is best for the nurse to use?
Use gestures or demonstrations as indicated
What intervention is most appropriate when communicating with a pt suffering from aphasia following a stroke?
Use simple, short sentences accompanied by visual cues to enhance comprehension.
What action will help a nurse communicate better with a stroke pt with aphasia?
Utilizing touch (may be the only way a pt with aphasia can express feelings)
A patient diagnosed with atrial fibrillation has been put on the oral anticoagulant warfarin. What instructions should the nurse give the patient?
-"The drug requires close monitoring" -"Do not stop the drug without informing the doctor"
What precautions should the nurse follow when feeding a pt with a stroke on the left side?
- Place the pt in high Fowler's position. -Place the pt in a chair with the head flexed forward
The nurse is providing education on the drug clopidogrel for a pt who experienced a transient ischemic attack (TIA). What pt statement indicates a further need for teaching?
"I need to keep in close contact with my health care provider because I need frequent blood tests to adjust the medication dose."
The registered nurse is teaching a student nurse about airway management for a pt who is a risk of aspiration. What statement made by the student nurse indicates effective learning?
"I will perform suctioning as needed."
The RN is teaching a student nurse about the proper way to communicate with a pt who has aphasia due to a stroke. What statement made by the student nurse indicates a need for further learning?
"I will try to force communication with the pt if the pt is upset."
A nurse is admitting a patient with a thrombotic stroke. The patient is nothing by mouth (NPO) but is requesting a drink of water. What response by a nurse is appropriate?
"It is not safe to allow you to have anything by mouth until a swallow assessment can be performed."
The registered nurse is teaching a student nurse about acute care for a patient with ischemic stroke. The patient's blood pressure is 230/120 mm Hg. What statement made by the student nurse indicates the need for further teaching?
"Large amounts of fluid should be provided."
A registered nurse is teaching a student nurse about the management of increased intracranial pressure in a patient who sustained a stroke. Which statement made by the student nurse indicates the need for further teaching?
"The pt should be placed in a supine position."
The nurse finds the wife of a pt who experienced a stroke one week ago crying in the hallway. The wife tells the nurse "I do not know if I can deal with this. He cried about everything and gets so moody with me." What is the best response for the nurse?
"This must be very frustrating for you"
A pt is admitted to the ED with right-sided facial drooping. When taking the pt's history, what information would be most significant?
"When did the facial drooping begin?"
A registered nurse is teaching a student nurse about tissue plasminogen activator (tPA) administration in a patient with ischemic stroke. What statement made by the student nurse indicates a need for further teaching?
"tPA should be administered within 12 hours of the onset of a stroke."
carotid endarterectomy
A patient is diagnosed with a transient ischemic attack due to carotid artery disease. Which surgical procedure would the primary health care provider suggest for this patient, as depicted in the image?
When planning for venous thromboembolism (VTE) prevention, what should the nurse place as the highest priority ?
Active and passive range-of-motion (ROM) exercises
The primary health care provider has prescribed nimodipine. What nursing action is appropriate?
Administer if heart rate is greater than 60 beats/minute.
In planning care of a pt with an acute stroke, what intervention would be appropriate for a nurse to delegate to a licensed practical/vocational nurse (LPN/LVN)?
Administer subcutaneous enoxaparin
A pt has left-sided hemiplegia following an ischemic stroke that was experienced four days earlier. How should the nurse best promote the health of the patient's integumentary system?
Alternate the pt's positioning between supine and side-lying
During the acute stage of a stroke, it is important for the nurse to included what intervention for a pt experiencing aphasia?
Ask simple yes or no questions
A patient has suffered a right-brain stroke. What should the nurse include in the safety measures immediately after the stroke?
Avoid using vests elevate the side rails use video monitors to observe the pt continuously
A patient presenting with stroke symptoms is being considered for fibrinolytic therapy. What assessment data would be important to communicate promptly to the prescribing health care provider?
Colonoscopy for evaluation of blood in the stools one week ago
While assessing a pt with paralysis due to a hemorrhagic stroke, the RN finds redness of the pt's skin. What would be the most appropriate intervention to prevent complications in the patient?
Changing the pt's position every 30 minutes to prevent damage to the epidermis and demis, manifested as permanent redness of the skin.
A pt who sustained a hemorrhagic stroke and has increased intracranial pressure reports to the nurse about loose stools. What is the priority nursing action?
Checking for stool impaction
A pt is admitted with a hemorrhagic stroke. What prescription should the nurse question?
Clopidogrel 75 mg PO once daily (anticoagulant -could cause further hemorrhage)
The nurse is feeding a pt by mouth for the first time after a stroke. What should the nurse feed the pt at this first feeding?
Crushed Ice (Gag reflex may be impaired due to dysphagia)
What would be the appropriate nursing intervention for optimizing musculoskeletal function of a pt with hemorrhagic stroke?
Discouraging pulling the pt's arm (shoulder displacement can occur if their arm is pulled)
The nurse assesses a patient experiencing visual disturbances and difficulty swallowing with a blood pressure of 280/180 mm Hg. What is the priority action by the nurse when the patient loses consciousness?
Ensure patent airway
A patient has experienced a right-brain stroke. What intervention would be most important to include in the plan of care?
Evaluate body positioning during all transfers.
What action can a nurse delegate to the unlicensed assistive personnel (UAP) to reduce fatigue for a pt recovering from a stroke at meal times?
cut up the meat for the pt
The primary health care provider finds neuromuscular and cognitive impairment in a patient with hemorrhagic stroke. What nursing intervention is most appropriate for the nurse to include in the plan of care?
encouraging independent exercise
What behavior is exhibited by a pt who has suffered a right-brain stroke?
impulsive and impatient
What action is most beneficial to a pt with a right-brain stroke?
remove clutter and obstacles
The patient with diabetes mellitus has had a right-hemispheric stroke. Which nursing intervention should the nurse plan to provide for this patient related to expected manifestations of this stroke?
safety measures