Adio CVA PrepU Ch. 62
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. A client with a CVA who is given heparin should be monitored for hemorrhage and bleeding at the subcutaneous injection site.
What is the chief cause of intracerebral hemorrhage (ICH)?
Uncontrolled hypertension. Primary intracerebral hemorrhage (ICH) from a spontaneous rupture of small arteries or arterioles accounts for approximately 80% of hemorrhagic strokes and is caused chiefly by uncontrolled hypertension.
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. Use short phrases, and give the client time between phrases to understand. Keeping extraneous and background noise such as the television to a minimum helps client concentrate on what is being said.
**A client has carotid atherosclerotic plaques, and a right carotid endarterectomy is performed. Two hours after surgery the client demonstrates progressive hypotension. The nurse should:
Notify the physician immediately. The cause of hypotension must be evaluated by the position.
**A client who had an infratentorial craniotomy is admitted to the intensive care unit after discharge from the postanesthesia care unit. Frequent assessments reveal that the client's intracranial pressure is increasing. The nurse should first:
Notify the physician of the finding. Immediate corrective therapy based on current assessments must be implemented.
Nursing management of the patient with receptive aphasia includes speaking slowing and clearly to assist the patient in forming the sounds.
Nursing management of the patient with cognitive deficits, such as memory loss, includes frequently reorienting the patient to time, place, and situation.
When communicating with a client who has sensory aphasia aka receptive aphasia, the nurse should use short, simple sentences.
Although sensory aphasia allows the client to hear words, it impairs the ability to comprehend their meaning. The nurse should use short, simple sentences to promote comprehension. A writing pad is only helpful for clients with expressive, not receptive, aphasia.
Agnosia is failure to recognize familiar objects perceived by the senses.
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Modifiable risk factors for TIAs and ischemic stroke include hypertension, diabetes, cardiac disease, smoking, alcoholism. Chronic alcoholism is a modifiable risk factor for TIAs and ischemic stroke.
Advanced age, gender, and race are nonmodifiable risk factors for stroke.
*Which of the following terms refer to the failure to recognize familiar objects perceived by the senses?
Agnosia. A specific type is Auditory agnosia is failure to recognize significance of sounds.
Nursing management of the patient with global aphasia includes speaking clearly to the patient in simple sentences and using gestures or pictures when able.
Nursing management of the patient with receptive aphasia includes speaking slowing and clearly to assist the patient in forming the sounds. Nursing management of the patient with cognitive deficits, such as memory loss, includes frequently reorienting the patient to time, place, and situation.
Regarding a CVA. One concern the APN addresses is a potential for falls. What would be most important for the APN to include in teaching of the client and family related to this concern?
Remove throw rugs and electrical cords from home environment. Also, clutter, and electrical cords from the client's home environment to reduce the potential for falls.
**After 3 months of rehabilitation after a craniotomy, a female client is still having some motor speech difficulty. To promote the client's use of speech the nurse should:
Support her efforts to communicate. Read cognition of effort is motivating.
*A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. She should carefully reposition the client often at least every hour
The client needs to be positioned so that a patent airway can be maintained. Fluid administration must be closely monitored to prevent complications such as increased intracranial pressure. The client must be maintained in a quiet environment to decrease the risk of re-bleeding.
** Indicates Mosby questions
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325 mg P.O. daily for a client who has experienced a TIA. The nurse should teach the client that the medication is to reduce the chance of blood clot formation.
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A 60-year-old African-American man has three risk factors: gender, age, and race. African Americans have almost twice the incidence of first stroke compared with Caucasians.
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A stroke may have impact the body's thermoregulation centers located in the hypothalamus.
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CVAs are prevented by reducing certain risk factors, such as hypertension, overweight, cardiac dysrhythmias like atrial fibrillation, and high blood cholesterol levels. Patients should not gain body weight.
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Cerebral hemorrhage, Cerebral aneurysm, ruptured cerebral arteries & arteriovenous malformation can lead to a hemorrhagic stroke.
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Damage to motor neurons may cause hemiparesis, hemaplegia, and a change in reflexes.
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Damage to the lower motor neurons may cause decreased muscle tone, flaccid muscle paralysis, and a decrease in or loss of reflexes.
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Health promotion efforts to decrease the risk for ischemic stroke involve encouraging a healthy lifestyle include a low-fat, low-cholesterol diet, and increasing exercise.
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If a client who recently experienced a stroke with accompanying left-sided paralysis is unaware of his left side. You should approach him on the right side.
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Interventions for dysphagia include placing food on the unaffected side of the mouth, allowing ample time to eat, assisting the patient with meals, and testing the patient's gag reflex prior to offering food or fluids.
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Patients with right hemisphere stroke exhibit partial perceptual deficits, left visual field deficit, and paralysis is weakness on the left side of the body.
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TIA symptoms may disappear within 1 hour; some continue for as long as 1 day. When the symptoms terminate, the client resumes his or her presymptomatic state.
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TIAs result from impaired blood circulation in the brain, which can be caused by atherosclerosis and arteriosclerosis, cardiac disease, or diabetes.
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The transcranial Doppler is useful in detecting severe intracranial stenosis, in evaluating the carotid and vertebrobasilar vessels, in assessing patterns and extent of collateral circulation in patients with arterial stenosis or occlusion, and in detecting microemboli.
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To be eligible for thrombolytic therapy, the client cannot be taking coumadin. Initiation of thrombolytic therapy must be within 3 hours in clients with ischemic stroke. The client is not eligible for thrombolytic therapy if she has had surgery within 14 days.
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When a client has one-sided weakness, the nurse should place the wheelchair on the client's unaffected side.
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warning signs fro risk factor for cerebral hemorrhage include Tinnitus, vomiting without nausea, LOC changes, and localized seizures.
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If narrowing of the carotid artery by atherosclerotic plaques is the cause of the TIAs, a carotid endarterectomy can be done. This is a surgical removal of atherosclerotic plaque
Another option is a balloon angioplast which can be performed to dilate the carotid artery and increase blood flow to the brain.
The primary symptoms of a client who experiences a right-sided stroke are left-sided weakness, impulsiveness, and poor judgment.
Aphasia is more commonly present when the dominant or left hemisphere is damaged.
Agraphia refers to disturbances in writing intelligible words.
Apraxia refers to inability to perform previously learned purposeful motor acts on a voluntary basis. Perseveration is the continued and automatic repetition of an activity, word, or phrase that is no longer appropriate.
*Which of the following terms refer to the inability to perform previously learned purposeful motor acts on a voluntary basis?
Apraxia. Verbal apraxia is a specific type of apraxia and refers to difficulty in forming and organizing intelligible words although the musculature is intact.
*A nurse is caring for a client who has returned to his room after a carotid endarterectomy. Which action should the nurse take first?
Ask client if he has trouble breathing. First assess the client's breathing. A complication of a carotid endarterectomy is an incisional hematoma, which could compress trachea causing breathing difficulty.
If warfarin is contraindicated as a treatment for stroke, which of the following medication is the best option?
Aspirin
Which of the following, if left untreated, can lead to an ischemic stroke?
Atrial fibrillation Atrial fibrillation if left untreated, it can lead to an ischemic stroke.
A client has experienced an ischemic stroke that has damaged the temporal lobe which is the lateral and superior portions lobe. Which of the following deficits would the nurse expect during assessment of this client?
Auditory agnosia. Damage to the occipital lobe can result in visual agnosia.
A client has just been diagnosed with an aneurysm. In planning discharge teaching for this client, what instructions should be delivered by the nurse to the client?
Avoid heavy lifting and extreme emotional situations, or straining of stools because they may increase intracranial pressure and headaches. Clients should be advised against taking opioid analgesics or including peanut butter, bread, or tart foods in diet, because of choking.
Which of the following is the most common side effect of tissue plasminogen activator tPA?
Bleeding. Patient is closely monitored for bleeding at IV insertion sites, gums, urine/stools, and intracranially by assessing changes in level of consciousness.
Client reports light-headedness, speech disturbance, and left-sided weakness that have lasted for several hours. In the examination, an abnormal sound is auscultated in her left carotid artery. What is the term for the auscultated discovery?
Bruit. is abnormal sound caused by blood flowing over the rough surface of one or both carotid arteries.
A nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform?
Call the physician immediately because the headache may be an indication that the aneurysm is leaking.
Manifestations of stroke depend on area of cortex, affected hemisphere, degree of blockage, and availability of collateral circulation. Manifestations of stroke are variable and depend on area of cerebral cortex and affected hemisphere, degree of blockage and adequate collateral circulation.
Clinical manifestations of a stroke do not depend on the cardiovascular health of the client or how quickly the clot can be dissolved. Clinical manifestations of a stroke are not "general" but individual.
Arterio-venous malformations are associated with hemorrhagic strokes. Trauma is associated with hemorrhagic strokes. Intracerebral aneurysm rupture is associated with hemorrhagic strokes.
Cocaine is a potent vasoconstrictor and may result in a life-threatening reaction, even with the individual's first use of the drug.
Regarding a transient ischemic attack, lifestyle changes would include Blood pressure control. Weight loss. Antiplatelet therapy.
Controlling hypertension, losing weight, and anticoagulant/antiplatelet therapy are typical medical interventions prescribed to prevent stroke.
Damage to the motor neurons may cause hemiparesis, hemiplegia, and a change in reflexes.
Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia.
** After a carotid endarterectomy, the client should be monitored for the complication of cranial nerve dysfunction. To monitor for this complication, the nurse should assess the client for:
Difficulty in swallowing. Muscles used for swallowing art innervated by the ninth glossopharyngeal and 10th Vegas cranial nerves.
Scotoma refers to a defect in vision in a specific area in one or both eyes.
Diplopia refers to double vision or the awareness of two images of the same object occurring in one or both eyes. Nystagmus refers to rhythmic, involuntary movements or oscillations of the eyes.
A patient diagnosed with a stroke is having difficulty forming words during communication. This would be appropriately documented as which of the following?
Dysarthria. Dysarthria is difficulty in forming words. Dysphagia is difficulty swallowing. Receptive aphasia is the inability to comprehend the spoken word.
After a stroke, a client is admitted to the facility. The client has left-sided weakness and an absent gag reflex.
Elevating the head of the bed to 30 degrees. Because the client's gag reflex is absent, elevating the head of the bed to 30 degrees helps minimize the client's risk of aspiration.
The nurse is caring for a client who has had a cerebrovascular accident. The client has difficulty swallowing. What intervention would it be important for the nurse to institute?
Encourage client to eat semisolid foods and cold foods. Semisolid and medium-consistency foods such as pudding, scrambled eggs, cooked cereals, and thickened liquids are easiest to swallow. Cold foods stimulate swallowing. Avoid tepid foods as they are more difficult to locate in the mouth.
** When assisting the family to help an aphasic member regain as much speech function as possible, the nurse should instruct them to:
Encourage the client to speak while being patient with each attempt. A factor in relearning speech is the client's motivation and effort. The more the client attempts to talk, the more likely speech will progress to its optimum level. Relearning is a slow process.
**Which of the following statements reflect nursing management of the patient with expressive aphasia?
Encourage the patient to repeat sounds of the alphabet
** A client is admitted to the hospital with weakness in the right extremities and a slight speech problem. Vital signs are normal. During the first 24 hours, the nurse should give priority to:
Evaluating the clients motor status. This assessment would indicate whether there is a progression of symptoms or improvement and assist the position in determining the diagnosis.
How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator aka tPA?
Every 15 minutes and vital signs except temperature should be taken every 15 minutes while receiving tPA infusion.
Patients with CVA should lose weight and therefore should minimize their volume of food consumption. The nurse may provide thickened commercial beverages, fortified cooked cereals, or scrambled eggs.
Foods such as peanut butter, bread, tart foods, dry or crisp foods, and chewy meats should also be avoided because they cause choking.
A client tells the nurse that they have transient ischemic attacks. The client reports having undergone a carotid artery surgery. In such a case, what important assessments should be performed by the nurse?
Frequent neurologic checks If the client undergoes carotid artery surgery, the nurse performs frequent neurologic checks to detect paralysis, confusion, facial asymmetry, or aphasia.
From which direction should a nurse approach a client who is blind in the right eye?
From the left side of the client
Which of the following is the most common motor dysfunction seen in patients diagnosed with stroke?
Hemiplegia which is caused by a lesion of the opposite side of the brain. Ataxia is impaired ability to coordinate movement. Diplopia is double vision. Hemiparesis is weakness of one side of the body.
**A client undergoes cerebral angiography for evaluation after an intracranial CT scan revealed a subarachnoid hemorrhage. The nurse checks frequently for signs and symptoms of complications associated with this procedure. Which findings indicate spasm or occlusion of a cerebral vessel by a clot.
Hemiplegia, seizures, and decreased level of consciousness. Spasm or occlusion of a cerebral vessel by a clot causes signs and symptoms similar to those of a stroke: hemiplegia, seizures, decreased LOC, aphasia, hemiparesis, and increased focal symptoms.
A nurse is teaching a community class that those experiencing symptoms of ischemic stroke need to enter the medical system early because thrombolytic therapy has a time window of only 3 hours.
Hint: THrombolytic & THree both have TH in the beginning.
Which of the following terms refers to blindness in the right or left halves of the visual fields of both eyes?
Homonymous hemianopsia which occurs with occipital lobe tumors.
Which disturbance results in loss of half of the visual field?
Homonymous hemianopsia. Hemianopsia may occur from stroke and may be temporary or permanent.
Damage to the temporal lobe can cause auditory agnosia.
If damage has occurred to the frontal lobe, learning capacity, memory, or other higher cortical intellectual functions may be impaired. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and lack of motivation.
*A client is receiving an I.V. infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant?
Increased urine output The therapeutic effect of mannitol is diuresis. A decreased LOC and elevated blood pressure may indicate lack of therapeutic effectiveness.
**Initially after a brain attack (CVA), a client's pupils are equal and reactive to light. Later the nurse assesses that the right pupil is reacting more slowly than the left and the systolic blood pressure is beginning to rise. The nurse recognizes that these adaptations are suggestive of:
Increasing intracranial pressure. Increased intracranial pressure is manifested by a sluggish pupillary reaction and elevation of the systolic blood pressure.
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.
**A female client manifests right-sided hemianopia as a result of a brain attack (CVA). The nurse should:
Instruct the client to scan her surrounding. The client has lost vision from the right visual field. Scanning compensate for loss.
Which of the following is a contraindication for the administration of tissue plasminogen activator aka t-PA.
Intracranial hemorrhage. Intracranial hemorrhage, neoplasm, or aneurysm is a contraindication to t-PA. However, Clinical diagnosis of ischemic stroke for those age 18 years of age or older, and a systolic BP less than or equal to 185 mm Hg are eligibility criteria for t-PA
You are caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke do you know this client has?
Ischemic. Ischemic strokes occur when a thrombus or embolus obstructs an artery carrying blood to the brain about 80% of strokes are the ischemic variety.
** The husband of a client with aphasia as a result of a brain attack (CVA) asks whether his wife's speech will ever return. The nurse should respond:
It is hard to say how much improvement will occur. Recovery from aphasia is a continuous process. The amount of recovery cannot be predicted.
Which of the following symptoms characterizes Korsakoff syndrome? Psychosis, disorientation, delirium, insomnia, and hallucinations
Korsakoff syndrome is a personality disorder characterized by psychosis, disorientation, delirium, insomnia, and hallucinations.
A client has experienced an ischemic stroke that has damaged the lower motor neurons of the brain. Which of the following deficits would the nurse expect during assessment?
Lack of deep tendon reflexes.
Which of the following antiseizure medication has been found to be effective for post-stroke pain?
Lamotrigine aka Lamictal The antiseizure medication lamotrigine (Lamictal) has been found to be effective for post-stroke pain.
What is indicative of a left hemisphere stroke?
Left hemisphere damage causes aphasia, slow, cautious behavior, and altered intellectual ability.
A client has experienced an ischemic stroke that has damaged the frontal lobe of his brain. Which of the following deficits does the nurse expect to observe during assessment?
Limited attention span and forgetfulness Damage to frontal lobe impairs learning capacity, memory, or other higher cortical intellectual functions. and may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and a lack of motivation.
**To prevent a client, who has had a brain attack (CVA) 2 days ago, from developing plantar flexion the nurse should:
Maintain the feed at right angles to the legs. This position produces dorsiflexion of the feet and prevents the tendons from shortening, preventing foot-drop.
Modifiable risk factors for ischemic stroke include hypertension, atrial fibrillation, hyperlipidemia, diabetes mellitus, smoking, asymptomatic carotid stenosis, obesity, and excessive alcohol consumption.
Non-modifiable risk factors for ischemic stroke include include advanced age, gender, and race.
Which of the following is the initial diagnostic test for a stroke?
Noncontrast C T scan. Further diagnostics include a carotid Doppler, ECG, and a transcranial Doppler.
Which of the following is the initial diagnostic in suspected stroke?
Noncontrast computed tomography (CT) An ischemic infarction will not be readily visible on initial CT scan if it is performed within the first few hours after symptoms onset; however, evidence of bleeding will almost always be visible.
Nursing management of the patient with expressive aphasia includes encouraging the patient to repeat sounds of the alphabet.
Nursing management of the patient with global aphasia includes speaking clearly and in simple sentences and using gestures or pictures when able.
**A client having a brain attack CVA is brought to the emergency department. The vital signs are P, 78; R, 16; and BP, 120/80. The change in this client's vital signs that would indicate increasing intracranial pressure (ICP) requiring notification of the physician would be:
P, 50; R, 22; BP, 140/60 Increasing intracranial pressure is evidenced by an increased pulse pressure and blood pressure and a decrease pulse rate. The physician should be notified.
*A nurse is planning care for a client who experienced a stroke in the right hemisphere of his brain. What should the nurse do?
Provide close supervision because of the client's impulsiveness and poor judgment.
Global aphasia is a combination of expressive and receptive aphasia and presents tremendous challenge to the nurse to effectively communicate with the patient.
Receptive aphasia is inability to understand language, written or spoken. Patient can speak normal grammar, syntax, rate, and intonation but cannot express meaningfully using language. Expressive aphasia is characterized by loss of ability to produce language spoken or written
A nurse is completing discharge teaching for the client who has left-sided hemiparesis following a stroke. When investigating the client's home environment, the nurse should focus on which nursing diagnosis?
Risk for injury. Because of decreased physical mobility, a client with recent left-sided hemiparesis is at risk for falls in the home setting.
**On the evening before discharge from the hospital, a client has a hypertensive crisis and a brain attack (CVA). Initially the nurse should place the client in a:
Side-lying position. Disposition will neither race intracranial pressure nor interfere with respirations and will permit world secretions to drink from the mouth by gravity.
What is indicative of a right hemisphere stroke?
Spatial-perceptual deficits.
A client who is at high-risk for a cerebrovascular accident has medication ordered to lower their cholesterol and to prophylactically anticoagulate them. What specific agent might be diagnosed for this client?
Specific agents include daily aspirin as well as antiplatelet or anticoagulant therapy such as clopidogrel aka Plavix), ticlopidine aka Ticlid), warfarin aka Coumadin, and dipyridamole aka Persantine. Heparin is not the drug of choice for prophylactic anticoagulation therapy.
If damage has occurred to the frontal lobe, learning capacity, memory, or other higher cortical intellectual functions may be impaired.
Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and lack of motivation.
**When caring for an unconscious client with increasing intracranial pressure, the nursing intervention that is contraindicated would be:
Suctioning oropharynx routinely. Although this is done to maintain an airway, it is not done routinely because it increases intracranial pressure.
**A client has a history of progressive carotid and cerebral atherosclerosis and transient ischemic attacks. The nurse explains to the client that TIAs are:
Temporary episodes of neurologic dysfunction
**A client has a history of progressive carotid and cerebral atherosclerosis and transient ischemic attacks (TIAs). The nurse understands that TIAs are:
Temporary episodes of neurologic dysfunction. Narrowing of arteries supplying the brain causes temporary neurologic deficits that last for a short period. However, between attacks, neurologic functioning is normal.
Aneurysm rebleeding occurs most frequently during which timeframe after the initial hemorrhage?
The First 2 weeks and is considered a major complication.
Which of the following is accurate regarding a hemorrhagic stroke?
The Main presenting symptom is an "exploding headache." In ischemic stroke, functional recovery usually plateaus at 6 months;
A client who's paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis?
The client demonstrates understanding of safety measures related to paralysis when he uses a mirror to inspect his skin. The mirror enables the client to inspect all areas of the skin for signs of breakdown without the help of staff or family members.
A patient with impaired swallowing should be helped to eat food with texture. Sit patient upright , flex patient's chin toward the chest, feed slowly & promote easy swallowing to reduce risk of aspiration or airway obstruction.
The patient should be allowed to rest before meals because fatigue may interfere with coordination and following instructions. Liquids should be offered frequently but in small quantities.
Administering heparin, an anticoagulant, could increase the bleeding associated with hemorrhagic stroke.
The physician may use dexamethasone to decrease cerebral edema and pressure;
The nurse is caring for a client with a cerebral aneurysm. Why does the nurse limit the interaction of visitors or family members with the client with an aneurysm?
The stimulation can increase intracranial pressure (ICP) or trigger a seizure.
What is the treatment window for thrombolytic therapy
Three hours. Rapid diagnosis of stroke and initiation of thrombolytic therapy within 3 hours for ischemic stroke leads to decrease size of stroke and improvement in functional outcome after 3 months. HINT: THrombolytic & Three both begin with TH
Hypertension is a risk factor for cerebral hemorrhage, the nurse questions the client closely about warning signs and symptoms of hemorrhage. Which complaint is a possible indicator of cerebral hemorrhage in this client?
Tinnitus is commonly a warning sign of cerebral hemorrhage. Other warning signs include vomiting without nausea, a change in level of consciousness, and localized seizures.
A client is has right-sided weakness. Within 6 hours of being admitted, the neurologic deficits has resolved and the client was back to their pre-symptomatic state. The probable cause of the neurologic deficit was what.
Transient ischemic attack A transient ischemic attack TIA is a sudden, brief attack of neurologic impairment caused by a temporary interruption in cerebral blood flow.
** A 26-year-old, admitted with the diagnosis of subarachnoid hemorrhage, exhibits aphasia and hemiparesis. These neurologic deficits, which may be present immediately after a subarachnoid hemorrhage, are primarily caused by:
Vascular spasms. In an attempt to stop the bleeding, adjacent arteries constrict; This intern contributes to the ischemia responsible for urologic deficits
What is the primary initial symptoms of an ischemic stroke?
Weakness on one side of the body and difficulty with speech
**The nurse should plan to position a client who has experienced a subarachnoid hemorrhage:
With the head of the bed elevated. This uses the force of gravity to prevent additional intracranial pressure, which would intensify the ischemic manifestations of hemorrhage.
Damage to the occipital lobe can result in visual agnosia.
damage to the temporal lobe can cause auditory agnosia
Obesity is a risk factor for stroke. Other risk factors include a history of ischemic episodes, cardiovascular disease, diabetes mellitus, atherosclerosis of the cranial vessels and
hypertension, polycythemia, smoking, hypercholesterolemia, hormonal contraceptive use, emotional stress, family history of stroke, and advancing age.
