AHIV EXAM 4 & AHIII EXAM 5 | CH 41 Stroke |

How does the nurse respond when a patient who experienced a stroke reports food accumulating in the cheek of the affected side? "It is likely that switching you to a low-sodium diet will prevent this from occurring." "Next time you eat, try lifting your chin when you swallow." "A speech-language pathologist should provide an evaluation." "Make sure that you sit in a semi-Fowler position every time you eat."

"A speech-language pathologist should provide an evaluation." Rationale The speech-language pathologist identifies strategies to prevent food from accumulating in the cheek of the affected side of a patient recovering from a stroke. Switching the patient to a low-sodium diet will not help with swallowing problems. Sitting in a semi-Fowler position (15 to 45 degrees) will be not helpful for patients with a swallowing problem. The correct technique to improve swallowing is the chin-tuck method; however, the speech-language pathologist will assist the patient with tongue exercises that will help move the food bolus to the unaffected side. p. 908

After providing discharge teaching about rehabilitation for a patient who has had a stroke, the nurse identifies that which statement demonstrates understanding of the education? "Rehabilitation and physical therapy mean the same thing." "Frequent stimulation will help with the rehabilitation process." "The rehabilitation therapist will help identify changes needed at home." "I will no longer need to take blood pressure medication."

"The rehabilitation therapist will help identify changes needed at home." Rationale The rehabilitation therapist and home health professionals assist the patient and family in adapting the home environment to the patient's needs and assess the patient's need for therapy. Any medication regimen for the patient must be maintained. Rehabilitation is much more comprehensive than physical therapy. The family should develop a home routine that provides structure, repetition, and consistency. p. 908

An adult child of a patient who experienced a stroke that affected the frontal lobe tells the nurse, "My parent cries a lot and often can't state a reason for being upset." Which nursing response is best? "It sounds like your parent is depressed, so I will inform the health care provider." "When this part of the brain is affected, emotional lability may be a result." "A stroke in this part of the brain causes brainstem deterioration, which is the cause of this type of response." "Your parent is experiencing hemianopsia, which should begin to diminish over time."

"When this part of the brain is affected, emotional lability may be a result." Rationale If the frontal lobe has been injured by a stroke, the patient may experience emotional lability in which the patient laughs then cries, most often for no apparent reason. It is an uncontrollable response and should be explained to the family. Crying is not a symptom of brainstem deterioration, which would include respiratory problems, and it is not an exclusive symptom of depression. Hemianopsia leads to neglect of one side of the body. p. 905

How many categories are on the National Institutes of Health Stroke Scale (NIHSS)? 8 9 10 11

11 Rationale There are 11 categories of the NIHSS, including level of consciousness (LOC), LOC questions, and LOC commands; best gaze; visual; facial palsy; motor (arm); motor (leg); limb ataxia; sensory; best language; dysarthria; and extinction and inattention. There are more categories in the NIHSS than 8, 9, or 10. p. 904

Based on the American Stroke Association, alteplase can be given within how many hours from the onset of the symptoms of stroke? 1.5 hours 4.5 hours 6 hours 12 hours

4.5 hours Rationale 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 that fibrinolytic therapy is started within 4.5 hours of symptom onset for most patients. Alteplase may be given if there has been more than 1.5 hours since the onset of the symptoms of stroke. Alteplase is not recommended for patients if it has been more than 4.5 hours since the onset of the symptoms of stroke. p. 906

A patient who weighs 165 lb will begin receiving IV alteplase to treat an ischemic stroke. The nurse expects to administer how many milligrams of the medication in the first minute of the infusion? Record your answer using two decimal places. Use a leading zero if applicable.

6.75 mg Rationale Patients receiving IV alteplase should receive 0.9 mg/kg over 60 minutes with 10% of that dose given as a bolus over the first minute. This patient weighs 165 lb, or 75 kg. The total dose for this patient is 67.5 mg (0.9 × 75 = 67.5). Ten percent of that is 6.75 mg. p. 906

A male client was admitted with a left-sided stroke this morning. The assistive personnel asks about meeting the client's nutritional needs. Which response by the nurse is appropriate? a. "He is NPO until the speech-language pathologist performs a swallowing evaluation." b. "You may give him a full-liquid diet, but please avoid solid foods until he gets stronger." c. "Just be sure to add some thickener in his liquids to prevent choking and aspiration." d. "Be sure to sit him up when you are feeding him to make him feel more natural."

ANS: A Any client who has or is suspected of having a stroke should have nothing by mouth until he or she is evaluated for any swallowing problem by the speech-language pathologist (SLP). If dysphagia is present, the SLP makes specific recommendations for the client's plan of care which all staff members must follow to prevent choking and aspiration/aspiration pneumonia.

A client has a brain tumor and is receiving phenytoin (Dilantin). The spouse questions the use of the drug, saying that the client does not have a seizure disorder. What response by the nurse is correct? a. "Increased pressure from the tumor can cause seizures." b. "Preventing febrile seizures with a tumor is important." c. "Seizures always occur in clients with brain tumors." d. "This drug is used to sedate with a brain tumor."

ANS: A Brain tumors can lead to seizures as a complication. The nurse would explain this to the spouse. Preventing febrile seizures is not related to a tumor. Seizures are possible but do not always occur in clients with brain tumors. This drug is not used for sedation.

A client who had therapeutic hypothermia after a traumatic brain injury is slowly rewarmed to a normal core temperature. For which assessment finding would the nurse monitor during the rewarming process? a. Cardiac dysrhythmias b. Loss of consciousness c. Nausea and vomiting d. Fever

ANS: A Due to fluid and electrolyte changes that typically occur during the rewarming process, the nurse monitors for cardiac dysrhythmias. The other findings are not common during this process.

A nurse is providing community screening for risk factors associated with stroke. Which person would the nurse identify as being at the highest risk for a stroke? a. A 27-year-old heavy-cocaine user. b. A 30-year-old who drinks a beer a day. c. A 40-year-old who uses seasonal antihistamines. d. A 65-year-old who is active and on no medications.

ANS: A Heavy drug use, particularly cocaine, is a risk factor for stroke. Heavy alcohol use is also a risk factor, but one beer a day is not considered heavy drinking. Antihistamines may contain phenylpropanolamine, which also increases the risk for stroke, but this person uses them seasonally and there is no information that they are abused or used heavily. The 65 year old has only age as a risk factor

A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The patient's spouse is very frustrated, stating that the patient's personality has changed and the situation is very difficult. What response by the nurse is most appropriate? a. Explain that personality changes are common following brain injuries. b. Ask the client why he or she is acting out and behaving differently. c. Refer the client and spouse to a head injury support group. d. Tell the spouse that this is expected and he or she will have to learn to cope.

ANS: A Personality and behavior often change permanently after head injury. The nurse will explain this to the spouse. Asking the client about his or her behavior isn't useful because the patient probably cannot help it. A referral might be a good idea, but the nurse needs to do something in addition to just referring the couple. Telling the spouse to learn to cope belittles his or her concerns and feelings.

A client is admitted with a sudden decline in level of consciousness. What is the nursing action at this time? a. Assess the client for hypoglycemia and hypoxia. b. Place the client on his or her side. c. Prepare for administration of a fibrinolytic agent. d. Start a continuous IV heparin sodium infusion.

ANS: A The cause of a sudden decline in level of consciousness may or may not be related to a neurologic health problem. Therefore, the client must be evaluated for other common causes, especially hypoglycemia and hypoxia. Placing the client on his or her side may be helpful to prevent aspiration in case the client experiences vomiting, but the clinical situation does not indicate that the client has nausea or vomiting. Administering either an anticoagulant like heparin or a fibrinolytic agent assumes that the client has an acute ischemic stroke, which has not been confirmed through imaging tests.

A client is admitted with a diagnosis of cerebellar stroke. What intervention is most appropriate to include on the client's plan of care? a. Ambulate only with a gait belt. b. Encourage double swallowing. c. Monitor lung sounds after eating. d. Perform postvoid residuals.

ANS: A The client who has a cerebellar stroke would be expected to have ataxia, an abnormal gait. For the client's safety, he or she should have assistance and use a gait belt when ambulating. Ataxia is not related to swallowing, aspiration, or voiding.

The nurse assesses a client who has a mild traumatic brain injury (TBI) for signs and symptoms consistent with this injury. What signs and symptoms does the nurse expect? (Select all that apply.) a. Sensitivity to light and sound b. Reports "feeling foggy" c. Unconscious for an hour after injury d. Elevated temperature e. Widened pulse pressure

ANS: A, B A mild TBI would possibly lead to sensitivity to light and sound and a feeling of mental fogginess. The patient would have been unconscious for less than 30 minutes. An elevated temperature is not related. A widened pulse pressure is indicative of increased intracranial pressure, not a mild TBI.

The nurse would recognize which signs and symptoms as consistent with brainstem tumors? (Select all that apply.) a. Hearing loss b. Facial pain c. Nystagmus d. Vomiting e. Hemiparesis

ANS: A, B, C Hearing loss (CN VIII), facial pain (CN V), and nystagmus (CN III, IV, and VI) all are indicative of a brainstem tumor because these cranial nerves originate in the brainstem. Vomiting and hemiparesis are more indicative of cerebral tumors

A nurse is caring for a group of stroke patients. Which clients would the nurse consider referring to a mental health provider? (Select all that apply.) a. Female client who exhibits extreme emotional lability b. Male client with an initial National Institutes of Health (NIH) Stroke Scale score of 38 c. Female client with mild forgetfulness and a history of depression d. Male client who has a past hospitalization for a suicide attempt e. Male client who is unable to walk or eat 3 weeks poststroke

ANS: A, B, C, D, E Patients most at risk for poststroke depression are those with a previous history of depression, severe stroke (NIH Stroke Scale score of 38 is severe), and poststroke physical or cognitive impairment.

The nurse is assessing a client who has symptoms of stroke. What are the leading causes of a stroke for which the nurse would assess for this client? (Select all that apply.) a. Heavy alcohol intake b. Diabetes mellitus c. Elevated cholesterol d. Obesity e. Smoking f. Hypertension

ANS: A, B, C, D, E, F The leading causes of stroke include all of these factors.

Based on the known risk factors for stroke, which health promotion practices would the nurse teach a client to promote heart health and prevent strokes? (Select all that apply.) a. Blood pressure control b. Aspirin use c. Smoking cessation d. Low carbohydrate diet e. Cholesterol management f. Increased red wine consumption

ANS: A, B, C, E The evidence-based health promotion practices include blood pressure control, aspirin use, smoking cessation, and cholesterol management. There is no consensus on which diet is best to promote heart health and red wine does not protect the heart or prevent strokes.

The nurse is caring for a client with increasing intracranial pressure (ICP) following a stroke. Which evidence-based nursing actions are indicated for this client? (Select all that apply.) a. Hyperoxygenate the client before and after suctioning. b. Avoid sudden or extreme hip or neck flexion. c. Provide oxygen to maintain an SaO2 of 95% or greater. d. Maintain the client in a supine position at all times. e. Avoid clustering care nursing activities and procedures. f. Provide environmental stimulation to improve cognition.

ANS: A, B, C, E These precautions help prevent further increases in ICP. Clustering nursing activities and procedures and providing stimulation can increase ICP and should be avoided.

The nurse is preparing for discharge of a client who had a carotid artery angioplasty with stenting to prevent a stroke. For which signs and symptoms with the nurse teach the family to report to the primary health care provider immediately? (Select all that apply.) a. Muscle weakness b. Hoarseness c. Acute confusion d. Mild neck discomfort e. Severe headache f. Dysphagia

ANS: A, B, C, E, F Muscle weakness, acute confusion, severe headache, and dysphagia are all signs and symptoms that could indicate that a stroke occurred. Hoarseness and severe neck pain and swelling may occur as a result of the interventional radiologic procedure.

A nurse cares for older clients who have traumatic brain injury. What does the nurse understand about this population? (Select all that apply.) a. Admission can overwhelm the coping mechanisms for older clients. b. Alcohol is typically involved in most traumatic brain injuries for this age-group. c. These clients are more susceptible to systemic and wound infections. d. Other medical conditions can complicate treatment for these clients. e. Very few traumatic brain injuries occur in this age-group.

ANS: A, C, D Older adults often tolerate stress poorly, which includes being admitted to a hospital that is unfamiliar and noisy. Because of decreased protective mechanisms, they are more susceptible to both local and systemic infections. Other medical conditions can complicate their treatment and recovery. Alcohol is typically not related to traumatic brain injury in this population; such injury is most often from falls and motor vehicle crashes.

A client is receiving IV alteplase and reports a sudden severe headache. What is the nurse's first action? a. Perform a comprehensive pain assessment. b. Discontinue the infusion of the drug. c. Conduct a neurologic assessment. d. Administer an antihypertensive drug.

ANS: B A severe headache may indicate that the client's blood pressure has markedly increased and, therefore, the drug should be stopped immediately as the first action. The nurse would then perform the appropriate assessments and possibly administer an antihypertensive medication.

The nurse is teaching assistive personnel (AP) about care for a male client diagnosed with acute ischemic stroke and left-sided weakness. Which statement by the AP indicates understanding of the nurse's teaching? a. "I will use "yes" and "no" questions when communicating with the client." b. "I will remind the client frequently to not get out of bed without help." c. "I will offer a urinal every hour to the client due to incontinence." d. "I will feed the client slowly using soft or pureed foods."

ANS: B The client who has left-sided weakness has likely had a right-sided stroke in the brain. Clients who have strokes on the right side of the brain tend to be very impulsive and exhibit poor judgment. Therefore, to keep the client safe, the staff will need to remind the client to stay in bed unless he has assistance to prevent falling. There is no evidence in the clinical situation that the client has aphasia (which is less common in those with right-sided strokes), difficulty swallowing, or urinary incontinence.

After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes, acute confusion, and restlessness. The client has IV fluids running at 75 mL/hr. What action by the nurse would the nurse take first? a. Assess the client's urinary output. b. Assess the client's serum sodium level. c. Increase the rate of the IV infusion. d. Provide oral care every hour.

ANS: B This client has signs and symptoms of hypernatremia, which is a possible complication after craniotomy. The nurse would assess the client's serum sodium level first and then possibly increase the rate of the IV infusion. Providing oral care is also a good option but does not take priority over assessing laboratory results.

A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak, and felt numbness in his left leg. Currently the client's neurologic examination is normal. About what drug would the nurse plan to teach the patient? a. Alteplase b. Clopidogrel c. Heparin sodium d. Mannitol

ANS: B This client's signs and symptoms are consistent with a transient ischemic attack, and the client would likely be prescribed aspirin or clopidogrel to prevent platelet aggregation on discharge. Alteplase is used for ischemic stroke. Heparin and mannitol are not used for this condition.

A client is admitted with a confirmed left middle cerebral artery occlusion. Which assessment findings will the nurse expect? (Select all that apply.) a. Ataxia b. Dysphagia c. Aphasia d. Apraxia e. Hemiparesis/hemiplegia f. Ptosis

ANS: B, C, D, E, F All of these assessment findings are common in clients who have a stroke caused by an occlusion of the left middle cerebral artery with the exception of ataxia (most often present in clients who have cerebellar strokes). This artery supplies the majority of the left side of the brain where motor, sensory, speech, and language centers are located.

A nurse is discharging a client from the emergency department who has a mild traumatic brain injury. What information obtained from the client represents a possible barrier to self-management? (Select all that apply.) a. Does not want to purchase a thermometer. b. Is allergic to acetaminophen. c. Laughing, says "Strenuous? What's that?" d. Lives alone and is new in town with no friends. e. Plans to have a beer and go to bed once home.

ANS: B, D, E Clients who have mild traumatic brain injuries should take acetaminophen for headache. An allergy to this drug may mean that the patient takes aspirin or ibuprofen, which should be avoided. The patient needs neurologic checks every 1 to 2 hours, and this client does not seem to have anyone available who can do that. Alcohol needs to be avoided for at least 24 hours. A thermometer is not needed. The patient laughing at strenuous activity probably does not engage in any kind of strenuous activity, but the nurse should confirm this

A client is admitted with a traumatic brain injury. What is the nurse's priority assessment? a. Complete neurologic assessment b. Comprehensive pain assessment c. Airway and breathing assessment d. Functional assessment

ANS: C Although the client has a brain injury, the most important assessment is to assess the client's ABCs, which includes airway, breathing, and circulation. The other assessments are performed later after the client is stabilized.

A client experiences impaired swallowing after a stroke and has worked with speech-language pathology on eating. What nursing assessment best indicates that the expected outcome for this problem has been met? a. Chooses preferred items from the menu. b. Eats 75 to 100% of all meals and snacks. c. Has clear lung sounds on auscultation. d. Gains 2 lb (1 kg) after 1 week.

ANS: C Impaired swallowing can lead to aspiration and then aspiration pneumonia, so the expected outcome for this problem is to experience no aspiration. Clear lung sounds is the best indicator that aspiration has not occurred. Choosing menu items is not related to this problem. Eating meals does not indicate that the client is not still aspirating. A weight gain indicates improved nutrition but still does not show a lack of aspiration.

A client who is experiencing a traumatic brain injury has increasing intracranial pressure (ICP). What drug will the nurse anticipate to be prescribed for this client? a. Phenytoin b. Lorazepam c. Mannitol d. Morphine

ANS: C Increased intracranial pressure is often the result of cerebral edema as a result of traumatic brain injury. Therefore, as osmotic diuretic such as mannitol or a loop diuretic like furosemide is administered. The other drugs are not appropriate to manage increasing ICP.

The nurse is preparing a client for discharge from the emergency department after experiencing a transient ischemic attack (TIA). Before discharge, which factor would the nurse identify as placing the client at high risk for a stroke? a. Age greater than or equal to 75 b. Blood pressure greater than or equal to 160/95 c. Unilateral weakness during a TIA d. TIA symptoms lasting less than a minute

ANS: C The client who has a TIA is at risk for a stroke is he or she has one-sided (unilateral) weakness during a TIA. Risk factors also include an age greater than or equal to 60, blood pressure greater than or equal to 140/90 (either or both systolic and diastolic), and/or a long duration of TIA symptoms. One minute is not a very long time for symptoms to occur.

The nurse is caring for four clients with traumatic brain injuries. Which client would the nurse assess first? a. Client with amnesia for the incident b. Client who has a Glasgow Coma Scale score of 12 c. Client with a PaCO2 of 36 mm Hg and on a ventilator d. Client who has a temperature of 102° F (38.9° C)

ANS: D A fever is a poor prognostic indicator in patients with brain injuries. The nurse should see this client first. A Glasgow Coma Scale score of 12, a PaCO2 of 36, and amnesia for the incident are all either expected or positive findings.

The nurse is preparing to administer IV alteplase for a client diagnosed with an acute ischemic stroke. Which statement is correct about the administration of this drug? a. The recommended time for drug administration is within 90 minutes after admission to the emergency department. b. The drug is given in a bolus over the first 3 minutes followed by a continuous infusion. c. The maximum dosage of the drug, including the bolus, is 120 mg intravenously. d. The drug is not given to clients who are already on anticoagulant or antiplatelet therapy.

ANS: D Alteplase is a thrombolytic which dissolves clots and can cause bleeding as an adverse effect. Clients who are already taking an anticoagulant or antiplatelet agent are at risk for bleeding and therefore they are not candidates for alteplase therapy.

A nurse receives a hand-off report on a female client who had a left-sided stroke with homonymous hemianopsia. What action by the nurse is most appropriate for this client? a. Assess for bladder and bowel retention and/or incontinence. b. Listen to the client's lungs after eating or drinking for diminished breath sounds. c. Support the client's left side when sitting in a chair or in bed. d. Remind the client to move her head from side to side to increase her visual field.

ANS: D Homonymous hemianopsia is blindness on the same side of both eyes. The client must turn his or her head to see the entire visual field. This condition is not related to bladder function, difficulty swallowing, or lack of trunk control.

A client with a severe traumatic brain injury has an organ donor card in his wallet. Which nursing action is appropriate? a. Request a directive form the client's primary health care provider. b. Ask the family if they agree to organ donation for the client. c. Wait until brain death is determined before acting on organ donation. d. Contact the local organ procurement organization as soon as possible.

ANS: D The appropriate nursing action is to respect the client's desire to be an organ donor and contact the local organ procurement organization even if family members do not agree. In most agencies, the primary health care provider does not have to write an order or directive to approve the organ donation. Family consent is not required

The nurse is caring for a client who had a hemorrhagic stroke. Which assessment finding is the earliest sign of increasing intracranial pressure (ICP) for this client? a. Projectile vomiting b. Dilated and nonreactive pupils c. Severe hypertension d. Decreased level of consciousness

ANS: D The earliest sign of increasing ICP is decreased level of consciousness. The other signs occur later.

The nurse is taking a history from a daughter about her father's onset of stroke signs and symptoms. Which statement by the daughter indicates that the client likely had an embolic stroke? a. Client's symptoms occurred slowly over several hours. b. Client because increasingly lethargic and drowsy. c. Client reported severe headache before other symptoms. d. Client has a long history of atrial fibrillation.

ANS: D The major cause of embolic strokes is a history of heart disease, especially atrial fibrillation. Most clients who have an embolic stroke have acute sudden neurologic symptoms but stay alert rather than lethargic. Decreasing level of consciousness and severe headache are more common in clients who have hemorrhagic strokes.

A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for the nurse to obtain? a. Loss of bladder control b. Other medical conditions c. Progression of symptoms d. Time of symptom onset

ANS: D The time limit for initiating fibrinolytic therapy for a stroke is 3 to 4.5 hours, so the exact time of symptom onset is the most important information for this client. The other information is not as critical.

According to the Centers for Disease Control and Prevention (CDC), which group is at the highest risk for stroke? White men Latino men Black women Alaskan Native men

Alaskan Native men Rationale Alaskan-Native and American Indian patients are at the highest risk for stroke. Black men and women are at a higher risk than their white counterparts, and Latino men are at a higher risk than their non-Hispanic counterparts, but these groups are all at a lower risk than Alaskan-Native men and women. p. 901

The nurse expects that which medication will be prescribed for a patient with an acute ischemic stroke whose onset of symptoms was 2 hours before hospitalization? Dopamine to maintain blood pressure Epinephrine to promote vasoconstriction Alteplase to prevent cerebral infarction Verapamil to prevent ventricular dysrhythmias

Alteplase to prevent cerebral infarction Rationale IV (systemic) fibrinolytic therapy (also called thrombolytic therapy) for an acute ischemic stroke dissolves the cranial artery occlusion to re-establish blood flow and prevent cerebral infarction. IV alteplase is the only drug approved at this time for the treatment of acute ischemic stroke. Dopamine would be contraindicated; a rise in blood pressure would increase the risk for complications. Epinephrine would not be indicated because vasoconstriction would lead to more symptoms. There is no evidence that the patient is experiencing a dysrhythmia. p. 906

The nurse identifies which etiologic factor when reviewing the history of a patient who is hospitalized with an embolic stroke? Atrial fibrillation Aortic aneurysm Diabetes mellitus Irritable bowel disease

Atrial fibrillation Rationale The source of most embolic strokes is typically the heart. Emboli occur in patients with a history of atrial fibrillation, ischemic heart disease, or myocardial infarction. Diabetes, aortic aneurysm, and irritable bowel disease are not primary risk factors. p. 900

Which nursing intervention helps prevent increased intracranial pressure (ICP) after a stroke? Careful monitoring of body temperature Providing oxygen therapy for oxygen saturation less than 90% Hyperoxygenating the patient before and after suctioning Clustering nursing procedures

Careful monitoring of body temperature Rationale Patients who have had a stroke are at increased risk for increased ICP for 24 to 48 hours after the stroke. The nurse should carefully monitor temperature because a temperature elevation can increase this risk. The nurse should provide oxygen therapy to prevent hypoxia for patients with oxygen saturation less than 95% or per agency or primary health care provider protocol or prescription. The nurse should hyperoxygenate the patient before and after suctioning to avoid transient hypoxemia and resultant ICP elevation from dilation of cerebral arteries. The nurse should avoid the clustering of nursing procedures (e.g., giving a bath followed immediately by changing the bed linen). When multiple activities are clustered in a narrow time period, the effect on ICP can be dramatic elevation. pp. 907-908

Abuse of which substance is most likely to result in a hemorrhagic stroke? Heroin Nicotine Cocaine Marijuana

Cocaine Rationale Cocaine and other stimulants can cause a sharp rise in blood pressure, which can result in a stroke. Specific risk factors for stroke include substance use disorder (especially cocaine and heavy alcohol consumption). Heroin and marijuana cause a decrease in respiration and cardiac function. Although nicotine is a stimulant, it would have to be consumed in huge doses to cause a stroke. p. 900

The nurse questions which collaborative intervention that is listed on a treatment plan for a patient who sustained a transient ischemic attack (TIA)? Prescriptions for aspirin and clopidogrel Inpatient hospitalization when the patient's diagnostic studies reveal carotid artery stenosis of 80% Medication to reduce high blood pressure Controlling diabetes (that is present) and keeping glucose levels within a target range of 120 to 200

Controlling diabetes (that is present) and keeping glucose levels within a target range of 120 to 200 Rationale Collaborative interventions for TIA include controlling diabetes (if present) and keeping glucose levels within a target range, typically 100 to 180 mg/dL. They also include prescribing antiplatelet drugs, typically aspirin or clopidogrel, to prevent thrombotic or embolic strokes (may be placed on a combination of both drugs). A patient who has a new onset of atrial fibrillation with the TIA or a TIA and carotid artery stenosis of greater than 70% will most likely be admitted, depending on agency protocol. Interventions also include reducing high blood pressure (the most common risk factor for stroke) by adding or adjusting drugs to lower blood pressure. p. 899

A patient tells the nurse, "My stroke caused me to have double vision, which makes a lot of my daily activities difficult to complete." Which nursing intervention will help the patient compensate? Covering the affected eye Placing objects in the patient's field of vision Approaching the patient on the affected side Encouraging turning the head from side to side

Covering the affected eye Rationale Covering the patient's eye with a patch prevents diplopia. The patient who is recovering from a stroke should always be approached on the unaffected side. The nurse may encourage side-to-side head turning for patients with hemianopsia (blindness in half of the visual field). Objects should be placed in the field of vision for the patient with a decreased visual field. pp. 909-910

A patient diagnosed with a stroke is receiving alteplase through one IV line. The nurse discovers that the second line has infiltrated and removes it. Which action is priority when the insertion site continues to bleed even after the nurse applies pressure on it? Discontinue the alteplase infusion. Take the patient's vital signs. Inform the primary health care provider. Assess the oxygen saturation level.

Discontinue the alteplase infusion. Rationale Alteplase is a fibrinolytic agent used for the treatment of ischemic or embolic stroke. Bleeding is a side effect of this medication caused by its pharmacotherapeutic action. Therefore if the nurse observes any bleeding that is not easily controlled, the alteplase infusion should be stopped immediately to prevent complications. The vital signs can be taken, and the primary health care provider can be informed after stopping the infusion. The priority is to stop the infusion; assessing the oxygen saturation does not stop the problem. p. 906

The nurse suspects which condition when a patient presents with symptoms of a stroke, including a slight headache, speech deficits, confusion, and blurred vision? Formation of a blood clot Bleeding into the brain tissue Bleeding into the subarachnoid space The break off of particles from aggregated thrombi

Formation of a blood clot Rationale A blood clot can lead to a thrombotic stroke, which causes a slight headache, speech deficits, confusion, and blurred vision. Bleeding into the brain leads to an intracerebral hemorrhage, which causes frequent and severe problems with nerve, spinal cord, or brain function. Confusion is a nonfocal neurologic symptom. Similarly, bleeding into the subarachnoid space leads to subarachnoid hemorrhage, which results in focal neurologic problems. The break off particles from aggregated thrombi enter into the carotid arteries leading to embolic stroke, which causes paralysis and difficulty in speaking and writing. p. 900

Which organ is the usual source of emboli in an embolic stroke? Lung Liver Heart Spleen

Heart Rationale Embolic strokes are caused by a thrombus or group of thrombi that break off from one area of the body and travel to the cerebral arteries via the carotid artery or vertebrobasilar system. The usual source of an emboli is the heart. Emboli that occur in the lungs can cause a pulmonary embolism. The liver and spleen are not typical sources of emboli. p. 900

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 Rationale In a hemorrhagic stroke, vessel integrity is interrupted, and bleeding occurs into the brain tissue or into the subarachnoid space. A stroke caused by an embolus (dislodged clot) is referred to as an embolic stroke. An acute ischemic stroke is caused by the occlusion (blockage) of a cerebral artery by either a thrombus or an embolus. A stroke that is caused by a thrombus (clot) is referred to as a thrombotic stroke. pp. 900-901

The nurse anticipates which outcome when a patient presents with symptoms of an embolic stroke? Improvement within 24 hours of onset Improvement over several days Improvement over weeks to months Permanent deficits are likely

Improvement over several days Rationale Embolic strokes have a sudden onset of symptoms that include paralysis and expressive aphasia and tend to resolve over hours to days. Transient ischemic attacks resolve quickly, within 24 hours. Thrombotic strokes have a slower onset and resolve more slowly, sometimes taking weeks to months. Permanent deficits may occur with thrombotic strokes. p. 900

The nurse suspects a stroke in which area of the brain when a patient presents to the emergency department with aphasia and right-sided hemiplegia? Brainstem Cerebellum Left cerebral hemisphere Right cerebral hemisphere

Left cerebral hemisphere Rationale The left cerebral hemisphere is the center for language and analytical thinking and also controls motor nerves on the right side of the body. A patient with deficits in these areas most likely has left cerebral involvement. Patients with brainstem or cerebellum involvement will have ataxia and may experience hemiparesis or quadriparesis. The right cerebral hemisphere is involved with visual and spatial awareness. p. 903

The nurse expects that which intervention will be listed on the plan of care for a patient who is admitted to the emergency department for a stroke? Monitor vital signs every 4 hours. Maintain the head of the patient in a midline, neutral position. Keep the head of the bed elevated at a 20-degree angle. Administer oxygen therapy for oxygen saturation levels less than 86%.

Maintain the head of the patient in a midline, neutral position. Rationale The head of the patient with the onset of stroke should be maintained in a midline, neutral position to promote venous drainage from the brain. The patient's vital signs should be monitored at least every 1 to 2 hours. The head of the bed should be elevated between 25 and 30 degrees to prevent a decreased blood flow to the brain. Oxygen therapy is provided for patients with oxygen saturation less than 92% to prevent hypoxia. p. 907

The nurse suspects which type of stroke when a patient presents with perpetual, spatial, and visual field deficits? Internal carotid artery stroke Middle cerebral artery stroke Anterior cerebral artery stroke Posterior cerebral artery stroke

Middle cerebral artery stroke Rationale Perpetual, spatial, and visual deficits are key features of middle cerebral artery strokes. Contralateral hemiparesis, hemianopsia, blurred vision, and blindness are key features of internal carotid artery strokes. Contralateral hemiparesis, aphasia, and amnesia are clinical features of anterior cerebral artery strokes. Loss of deep sensation, decreased touch sensation, aphasia, and amnesia are clinical features of posterior cerebral artery strokes. p. 903

The nurse reviews the medical record of a patient who is diagnosed with an acute ischemic stroke and identifies that which assessment finding is a contraindication for fibrinolytic therapy according to the American Stroke Association guidelines? patient age - 70 years NHISS score - 26 symptom onset - 3.5 hours before evaluation iNR - 1.1

NHISS Rationale The American Stroke Association guidelines for treatment with fibrinolytic therapy include administering the treatment within 4.5 hours of symptom onset, unless the patient is over 80 years old or has an NIHSS score greater than 25. The patient's INR is normal. p. 906

Which risk factor for stroke is modifiable? Age Sex Obesity Family history of hypertension

Obesity Rationale Obesity is a modifiable risk factor for stroke; a patient can lose weight with certain lifestyle changes. Age, sex, and family history of hypertension are risk factors for stroke, but they are not modifiable. p. 901

The nurse suspects which type of stroke when the assessment findings of a patient include perseveration, loss of deep sensation, and decreased touch sensation? Vertebrobasilar artery stroke Middle cerebral artery stroke Internal carotid artery stroke Posterior cerebral artery stroke

Posterior cerebral artery stroke Rationale The posterior cerebral arteries are a pair of blood vessels that supply oxygenated blood to the occipital lobe. Perseveration, loss of deep sensation, and decreased touch sensation are symptoms of posterior cerebral artery strokes. Perseveration is not a symptom of internal carotid artery, middle cerebral artery, and vertebrobasilar artery strokes. The vertebrobasilar artery supplies blood to the posterior part of the circle of Willis. The middle cerebral artery supplies blood to the cerebrum. The internal carotid artery supplies blood to the brain. p. 903

The nurse recognizes which condition when a patient experiences difficulty understanding spoken and written words and uses language that is meaningless? Mixed aphasia Global aphasia Receptive aphasia Expressive aphasia

Receptive aphasia Rationale Receptive aphasia occurs because of injury in the Wernicke area in the temporoparietal area. This leads to the patient having difficulty understanding spoken and written words, creating made-up words, and using meaningless speech. Mixed aphasia is difficulty in expression and reception, which includes difficulty speaking and writing. Global aphasia occurs because of severe damage in the receptive and expressive skills. Expressive aphasia occurs due to difficulty speaking and writing. p. 909

Before discharging a patient after carotid stent placement, the nurse teaches the patient and family to report which symptom to the primary health care provider immediately? Select all that apply. One, some, or all responses may be correct. Severe headache Weight gain Constipation Swelling at neck incisional site Hoarseness Muscle weakness

Severe headache Swelling at neck incisional site Hoarseness Muscle weakness Rationale Before a patient is discharged after carotid stent placement, the nurse should teach the patient and family to report these symptoms to the primary health care provider immediately: severe headache; change in loss of consciousness (LOC) or cognition (e.g., drowsiness, new-onset confusion); muscle weakness or motor dysfunction; severe neck pain; swelling at the neck incisional site; or hoarseness or dysphagia (due to nerve damage). Weight gain and constipation are not indicators of significant complications of carotid stent placement. p. 907

The nurse is caring for a patient 1 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 increased intracranial pressure (ICP)? The patient is no longer oriented to place. The patient reports numbness of the right leg. The patient has developed urinary incontinence. The patient has a blood pressure (BP) of 90/62 mm Hg.

The patient is no longer oriented to place. Rationale The patient with a recent stroke is at risk for increased ICP because of cerebral edema or ongoing intracranial hemorrhage. The first indication of increasing ICP is a change in the level of consciousness. If the patient is confused and disoriented to place, it indicates an increased ICP, and the primary health care provider should be notified immediately. Urinary incontinence in the patient may indicate focal deficit. Numbness in the right leg may be due to weakness and may be an effect of the stroke, but it does not indicate an increased ICP. A BP of 90/62 mm Hg indicates hypotension. Hypertension is a key feature of increased ICP. p. 907

Which statement describes the symptoms of a transient ischemic attack (TIA)? They typically resolve within 30 to 60 minutes. They are limited to the speech area. They manifest in the upper extremities. They last longer than 24 hours but less than a week.

They typically resolve within 30 to 60 minutes. Rationale By definition, the symptoms of a TIA resolve typically within 30 to 60 minutes. TIA symptoms can manifest as weakness in the arms, hands, or legs, and gait disturbance is typical. Speech deficits (aphasia, dysarthria) can result from TIA, but symptoms are not limited to this area. Typically, symptoms of a TIA resolve within 30 to 60 minutes but may last as long as 24 hours; they do not usually last for more than 24 hours. p. 898

The nurse recognizes that which patient assessment finding is consistent with a stroke in the right hemisphere? Slowness Unawareness of any deficit Anger and frustration Deficit in the right visual field

Unawareness of any deficit Rationale As a result of right-hemisphere lesions, the patient may be impulsive and seemingly unaware of any deficit. Deficit in the right visual field, slowness, and anger and frustration are the symptoms of a left-hemisphere stroke. p. 911

Which type of stroke has a key feature of coma? Vertebrobasilar artery stroke Internal carotid artery stroke Middle cerebral artery stroke Anterior cerebral artery stroke

Vertebrobasilar artery stroke Rationale Vertebrobasilar artery strokes occur when blood flow through the vertebrobasilar region is reduced or stopped. This may lead to a coma. Internal carotid artery strokes, middle cerebral artery strokes, and anterior cerebral artery strokes may not lead to coma. The internal carotid artery supplies blood to the brain. The middle cerebral artery supplies blood to the cerebrum. The anterior cerebral artery supplies oxygenated blood to most of the portions of the frontal lobes and superior medial parietal lobes. p. 903

A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The patient's spouse is very frustrated, stating that the patient's personality has changed and the situation is very difficult. What response by the nurse is most appropriate? a. Explain that personality changes are common following brain injuries. b. Ask the client why he or she is acting out and behaving differently. c. Refer the client and spouse to a head injury support group. d. Tell the spouse that this is expected and he or she will have to learn to cope.

a