Ch 67 Cerebrovascular disorders, Hinkle 67 Management of Patients with Cerebrovascular Disorders, Chapter 67, Management of Patients with Cerebrovascular Disorders
A patient is in the acute phase of an ischemic stroke. How long does the nurse know that this phase may last? a) Up to 1 week b) Up to 24 hours c) 1 to 3 days d) Up to 2 weeks
1 to 3 days The acute phase of an ischemic stroke may last 1 to 3 days, but ongoing monitoring of all body systems is essential as long as the patient requires care.
The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient? 1. Semi-Fowler's 2. Prone 3. High-Fowler's 4. Supine
1. Semi-Fowler's The head of the bed is elevated 15 to 30 degrees (semi-Fowler's position) to promote venous drainage and decrease intracranial pressure.
A nurse knows that, for a patient with an ischemic stroke, tPA is contraindicated if the blood pressure reading is: a) 170 mm Hg/105 mm Hg b) 185 mm Hg/110 mm Hg c) 190 mm Hg/120 mm Hg d) 175 mm Hg/100 mm Hg
190 mm Hg/120 mm Hg Elevated blood pressure (systolic >185; diastolic >110 mm Hg) is a contraindication to tPA.
How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tPA)? 1. Every 30 minutes 2. Every hour 3. Every 45 minutes 4. Every 15 minutes
4. Every 15 minutes Neurological assessment and vital signs (except temperature) should be taken every 15 minutes initially while the patient is receiving tPA infusion.
A 154-pound woman has been prescribed tPA (0.9 mg/kg) for an ischemic stroke. The nurse knows to give how many mg initially? -6.3 mg -7.5 mg -8.3 mg -10 mg
6.3 mg A person who weighs 154 lbs weighs 70 kg. To calculate dosage, multiply 70 × 0.9 mg/kg = 63 mg. The nurse gives 10% (6.3 mg) over 1 minute.
A patient presents to the emergency room with complaints of having an "exploding headache" for the last 2 hours. The patient is immediately seen by a triage nurse who suspects the patient is experiencing a stroke. Which of the following is a possible cause based on the characteristic symptom? a) Cerebral aneurysm b) Cardiogenic emboli c) Large artery thrombosis d) Small artery thrombosis
Cerebral aneurysm A cerebral aneurysm is a type of hemorrhagic stroke that is characterized by an exploding headache.
The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regime, to maintain a healthy weight, and to adopt a reasonable exercise program. This advice is based on research data that shows the most important risk factor for stroke is: a) Dyslipidemia b) Obesity c) Hypertension d) Smoking
Hypertension Hypertension is the most modifiable risk factor for either ischemic or hemorrhagic stroke. Unfortunately, it remains under-recognized and undertreated in most communities.
Which of the following antiseizure medication has been found to be effective for post-stroke pain? a) Carbamazepine (Tegretol) b) Lamotrigine (Lamictal) c) Topiramate (Topamax) d) Phenytoin (Dilantin)
Lamotrigine (Lamictal) The antiseizure medication lamotrigine (Lamictal) has been found to be effective for post-stroke pain.
Which of the following is the initial diagnostic test for a stroke? a) Noncontrast CT scan b) Transcranial Doppler studies c) ECG d) Carotid Doppler
Noncontrast CT scan The initial diagnostic test for a stroke is a nonconstrast CT scan performed emergently to determine if the event is ischemic or hemorrhagic. Further diagnostics include a carotid Doppler, ECG, and a transcranial Doppler. (less)
Which is the initial diagnostic test for a stroke?
Noncontrast computed tomography The initial diagnostic test for a stroke is nonconstrast computed tomography performed emergently to determine whether the event is ischemic or hemorrhagic. Further diagnostics include a carotid Doppler, electrocardiogram, and transcranial Doppler.
The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient? -High-Fowler's -Prone -Supine -Semi-Fowler's
Semi-Fowler's The head of the bed is elevated 15 to 30 degrees (semi-Fowler's position) to promote venous drainage and decrease intracranial pressure.
A patient diagnosed with an ischemic stroke should be treated within the first 3 hours of symptom onset with which of the following?
Tissue plasminogen activator (tPA) In 1996, the FDA approved the use of tissue plasminogen activator (tPA) for the treatment of acute ischemic stroke within the first 3 hours of symptom onset.
penumbra region
area of low cerebral blood flow
aphasia
inability to express oneself or to understand language
infarction
tissue necrosis in an area deprived of blood supply
A nurse is instructing the spouse of a client who suffered a stroke about the use of eating devices the client will be using. During the teaching, the spouse starts to cry and states, "One minute he is laughing, and the next he's crying; I just don't understand what's wrong with him." Which statement is the best response by the nurse? -"Emotional lability is common after a stroke, and it usually improves with time." -"This behavior is common in clients with stroke. Which does your spouse do more often? Laugh or cry?" -"You seem upset, and it may be hard for you to focus on the teaching, I'll come back later." -"You sound stressed; maybe using some stress management techniques will help."
"Emotional lability is common after a stroke, and it usually improves with time."
A client is prescribed sumatriptan for the treatment of migraine headache. Which client statement would indicate a need for additional teaching from the nurse?
"I use this to prevent migraines." Sumatriptan is a serotonin receptor agonist that stimulates serotonin receptors in the brain and causes vasoconstriction of the cerebral arteries and reduce/eliminate headaches and other symptoms associated with migraines. Sumatriptan is used during an attack and is not indicated for preventative migraine therapy.
Which interventions would be recommended for a client with dysphagia? Select all that apply.
-Assist the client with meals. -Test the gag reflex before offering food or fluids. -Allow ample time to eat. Interventions for dysphagia include placing food on the unaffected side of the mouth, allowing ample time to eat, assisting the client with meals, and testing the client's gag reflex before offering food or fluids.
A nurse is assisting with a community screening for people at high risk for stroke. To which of the following clients would the nurse pay most attention? 1. A 60-year-old African-American man 2. A 28-year-old pregnant African-American woman 3. A 62-year-old Caucasian woman 4. A 40-year-old Caucasian woman
1. A 60-year-old African-American man The 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.
A client with a history of atrial fibrillation has experienced a TIA. In an effort to reduce the risk of cerebrovascular accident (CVA), the nurse anticipates the priority medical treatment to include which of the following? 1. Anticoagulant therapy 2. Monthly prothrombin levels 3. Cholesterol-lowering drugs 4. Carotid endarterectomy
1. Anticoagulant therapy Anticoagulant or antiplatelet therapy can prevent clot formation associated with cardiac dysrhythmias such as atrial fibrillation. Cholesterol-lowering drugs can be ordered if indicated to manage atherosclerosis. Prothrombin and international normalized ratio (INR) levels may be ordered to monitor therapeutic effects of anticoagulant therapy. Carotid endarterectomy would be anticipated only when the carotids have narrowing from plaque.
The nurse is caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke does the nurse know this client has? 1. Ischemic 2. Hemorrhagic 3. Right-sided 4. Left-sided
1. 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 other options are incorrect.
A client admitted to the emergency department is being evaluated for the possibility of a stroke. Which assessment finding would lead the nurse to suspect that the client is experiencing a hemorrhagic stroke? 1. severe exploding headache 2. left-sided weakness 3. slurred speech 4. difficulty finding appropriate words
1. severe exploding headache A hemorrhagic stroke is often characterized by a severe headache (commonly described as the "worst headache ever") or as "exploding." Weakness and speech issues are more commonly associated with an ischemic stroke.
The nurse is caring for a client diagnosed with a hemorrhagic stroke. The nurse recognizes that which intervention is most important? 1. Monitoring for seizure activity 2. Maintaining a patent airway 3. Elevating the head of the bed to 30 degrees 4. Administering a stool softener
2. Maintaining a patent airway Maintaining the airway is the most important nursing intervention. Immediate complications of a hemorrhagic stroke include cerebral hypoxia, decreased cerebral blood flow, and extension of the area of injury. Providing adequate oxygenation of blood to the brain minimizes cerebral hypoxia. Brain function depends on delivery of oxygen to the tissues. Administering supplemental oxygen and maintaining hemoglobin and hematocrit at acceptable levels will assist in maintaining tissue oxygenation. All other interventions are appropriate, but the airway takes priority. The head of the bed should be elevated to 30 degrees, monitoring the client because of the risk for seizures, and stool softeners are recommended to prevent constipation and straining, but these are not the most important interventions.
The nurse is providing diet-related advice to a male patient following a cerebrovascular accident (CVA). The patient wants to minimize the volume of food and yet meet all nutritional elements. Which of the following suggestions should the nurse give to the patient about controlling the volume of food intake? 1. Provide a high-fat diet. 2. Provide thickened commercial beverages and fortified cooked cereals. 3. Include dry or crisp foods and chewy meats. 4. Always serve hot or tepid foods.
2. Provide thickened commercial beverages and fortified cooked cereals. Patients with CVA or other cerebrovascular disorders should lose weight and therefore should minimize their volume of food consumption. To ensure this, the nurse may provide thickened commercial beverages, fortified cooked cereals, or scrambled eggs. Patients should avoid eating high-fat foods, and serving foods hot or tepid will not minimize the volume consumed by the patient. 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 reports light-headedness, speech disturbance, and left-sided weakness that have lasted for several hours. In the examination, an abnormal sound is auscultated in an artery leading to the brain. What is the term for the auscultated discovery? 1. TIA 2. bruit 3. atherosclerotic plaque 4. diplopia
2. bruit A neurologic examination during an attack reveals neurologic deficits. Auscultation of the artery may reveal a bruit (abnormal sound caused by blood flowing over a rough surface within one or both carotid arteries). The term for the auscultated discovery is "bruit."
A patient presents to the emergency room with complaints of having an "exploding headache" for the last 2 hours. The patient is immediately seen by a triage nurse who suspects the patient is experiencing a stroke. Which of the following is a possible cause based on the characteristic symptom? 1. Cardiogenic emboli 2. Large artery thrombosis 3. Cerebral aneurysm 4. Small artery thrombosis
3. Cerebral aneurysm A cerebral aneurysm is a type of hemorrhagic stroke that is characterized by an exploding headache.
During assessment of cognitive impairment, post-stroke, the nurse documents that the patient was experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe? 1. Occipital 2. Parietal 3. Frontal 4. Temporal
3. Frontal Frontal lobe damage results in impaired learning capacity, memory, and other higher cortical intellectual functions.
A physician orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? 1. Phenytoin (Dilantin) 2. Methyldopa (Aldomet) 3. Heparin sodium 4. Dexamethasone (Decadron)
3. Heparin sodium Administering heparin, an anticoagulant, could increase the bleeding associated with hemorrhagic stroke. Therefore, the nurse should question this order to prevent additional hemorrhage in the brain. In a client with hemorrhagic stroke, the physician may use dexamethasone to decrease cerebral edema and pressure; methyldopa, to reduce blood pressure; and phenytoin, to prevent seizures.
A client is receiving an IV 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? 1. Decreased level of consciousness (LOC) 2. Elevated blood pressure 3. Increased urine output 4. Decreased heart rate
3. Increased urine output The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output. A decreased LOC and elevated blood pressure may indicate lack of therapeutic effectiveness. A decreased heart rate doesn't indicate that mannitol is effective.
Which of the following antiseizure medication has been found to be effective for post-stroke pain? 1. Phenytoin (Dilantin) 2. Carbamazepine (Tegretol) 3. Topiramate (Topamax) 4. Lamotrigine (Lamictal)
4. Lamotrigine (Lamictal) The antiseizure medication lamotrigine (Lamictal) has been found to be effective for post-stroke pain.
A patient is brought to the emergency department with a possible stroke. What initial diagnostic test for a stroke, usually performed in the emergency department, would the nurse prepare the patient for? 1. Carotid ultrasound study 2. Transcranial Doppler flow study 3. 12-lead electrocardiogram 4. Noncontrast computed tomogram
4. Noncontrast computed tomogram The initial diagnostic test for a stroke is usually a noncontrast computed tomography (CT) scan. This should be performed within 25 minutes or less from the time the patient presents to the emergency department (ED) to determine if the event is ischemic or hemorrhagic (the category of stroke determines treatment).
A patient is admitted via ambulance to the emergency room of a stroke center at 1:30 p.m. with symptoms that the patient said began at 1:00 p.m. Within 1 hour, an ischemic stroke had been confirmed and the doctor ordered tPA. The nurse knows to give this drug no later than what time? a) 5:30 p.m. b) 3:00 p.m. c) 4:00 p.m. d) 2:30 p.m.
4:00 p.m. Tissue plasminogen activator (tPA) must be given within 3 hours after symptom onset. Therefore, since symptom onset was 1:00 pm, the window of opportunity ends at 4:00 pm.
A client is admitted to the intensive care unit (ICU) with a diagnosis of cerebrovascular accident (CVA). Which assessment by the nurse provides the most significant finding in differentiating between ischemic and hemorrhagic strokes? a) Oropharyngeal suctioning as needed. b) Kepprais ordered for treatment of focal seizures. c) A unit of fresh frozen plasma is infusing. d) Neurological checks are ordered every 2 hours.
A unit of fresh frozen plasma is infusing. FFP is usedin the treatment of clotting deficiencies as seen with over dose of anticoagulants and would indicate a hemorrhagic stroke. Neuro checks ordered every 2 hours does not differentiate between types of strokes. Focal seizures can occur with any stroke and would not differentiate. Suctioning is a nursing action taken to maintain airway and does not indicate a specific type of stroke.
Which of the following terms refer to the inability to perform previously learned purposeful motor acts on a voluntary basis? a) Agraphia b) Perseveration c) Agnosia d) Apraxia
Apraxia Verbal apraxia refers to difficulty in forming and organizing intelligible words although the musculature is intact. Agnosia is failure to recognize familiar objects perceived by the senses. Agraphia refers to disturbances in writing intelligible words. Perseveration is the continued and automatic repetition of an activity or word or phrase that is no longer appropriate. (less)
Which of the following is the most common side effect of tissue plasminogen activator (tPA)? a) Increased intracranial pressure (ICP) b) Hypertension c) Headache d) Bleeding
Bleeding Bleeding is the most common side effect of tPA. The patient is closely monitored for bleeding (at IV insertion sites, gums, urine/stools, and intracranially by assessing changes in level of consciousness). Headache, increased ICP, and hypertension are not side effects of tPA.
The provider diagnoses the patient as having had an ischemic stroke. The etiology of an ischemic stroke would include which of the following? a) Cerebral aneurysm b) Cardiogenic emboli c) Intracerebral hemorrhage d) Arteriovenous malformation
Cardiogenic emboli Aneurysms, hemorrhages, and malformations are all examples of a hemorrhagic stroke. An embolism can block blood flow, leading to ischemia.
Which of the following insults or abnormalities can cause an ischemic stroke? a) Arteriovenous malformation b) Intracerebral aneurysm rupture c) Cocaine use d) Trauma
Cocaine use Cocaine is a potent vasoconstrictor and may result in a life-threatening reaction, even with the individual's first use of the drug. Arteriovenous malformations are associated with hemorrhagic strokes. Trauma is associated with hemorrhagic strokes. Intracerebral aneurysm rupture is associated with hemorrhagic strokes.
The nurse is caring for a patient with aphasia. Which of the following strategies will the nurse use to facilitate communication with the patient? -Speaking in complete sentences -Speaking loudly -Avoiding the use of hand gestures -Establishing eye contact
Establishing eye contact Explanation: The following strategies should be used by the nurse to encourage communication with a client with aphasia: face the client and establish eye contact, speak in your usual manner and tone, use short phrases, and pause between phrases to allow the client time to understand what is being said; limit conversation to practical and concrete matters; use gestures, pictures, objects, and writing; and as the client uses and handles an object, say what the object is. It helps to match the words with the object or action. Be consistent in using the same words and gestures each time you give instructions or ask a question, and keep extraneous noises and sounds to a minimum. Too much background noise can distract the client or make it difficult to sort out the message being spoken.
The nurse is caring for a patient with aphasia. Which of the following strategies will the nurse use to facilitate communication with the patient? a) Speaking in complete sentences b) Speaking loudly c) Avoiding the use of hand gestures d) Establishing eye contact
Establishing eye contact The following strategies should be used by the nurse to encourage communication with a patient with aphasia: face the patient and establish eye contact, speak in your usual manner and tone, use short phrases, and pause between phrases to allow the patient time to understand what is being said; limit conversation to practical and concrete matters; use gestures, pictures, objects, and writing; and as the patient uses and handles an object, say what the object is. It helps to match the words with the object or action, be consistent in using the same words and gestures each time you give instructions or ask a question, and keep extraneous noises and sounds to a minimum. Too much background noise can distract the patient or make it difficult to sort out the message being spoken. (less)
How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tPA)?
Every 15 minutes
From which direction should a nurse approach a client who is blind in the right eye?
From the left side of the client The nurse should approach the client from the left side so that the client can be aware of the nurse's approach. Likewise, personal items should be placed on the client's left side so that he can see them easily.
During assessment of cognitive impairment, post-stroke, the nurse documents that the patient was experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe?
Frontal Frontal lobe damage results in impaired learning capacity, memory, and other higher cortical intellectual functions.
A physician orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? a) Phenytoin (Dilantin) b) Methyldopa (Aldomet) c) Heparin sodium d) Dexamethasone (Decadron)
Heparin sodium Administering heparin, an anticoagulant, could increase the bleeding associated with hemorrhagic stroke. Therefore, the nurse should question this order to prevent additional hemorrhage in the brain. In a client with hemorrhagic stroke, the physician may use dexamethasone to decrease cerebral edema and pressure; methyldopa, to reduce blood pressure; and phenytoin, to prevent seizures.
Which disturbance results in loss of half of the visual field? a) Anisocoria b) Homonymous hemianopsia c) Nystagmus d) Diplopia
Homonymous hemianopsia Homonymous hemianopsia (loss of half of the visual field) may occur from stroke and may be temporary or permanent. Double vision is documented as diplopia. Nystagmus is ocular bobbing and may be seen in multiple sclerosis. Anisocoria is unequal pupils.
The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regimen, to maintain a healthy weight, and to adopt a reasonable exercise program. This advice is based on research data that shows the most important risk factor for stroke is:
Hypertension Hypertension is the most modifiable risk factor for either ischemic or hemorrhagic stroke. Unfortunately, it remains under-recognized and undertreated in most communities.
A client diagnosed with migraine headaches asks the nurse what he can do to help control the headaches and minimize the number of attacks he is having. What instructions should the nurse give this client? -When an attack occurs stay in a brightly lit area. -Write down any adverse drug effects. -Identify and avoid factors that precipitate or intensify an attack. -Keep a record of activities following an attack.
Identify and avoid factors that precipitate or intensify an attack. The nurse instructs the client to follow the indications and dosage regimen for medication, notify the physician of any adverse drug effects, and identify and avoid factors that precipitate or intensify an attack. Keeping a food diary may help identify foods that trigger attacks. The client can keep a record of the attacks, including activities before the attack, and environmental or emotional circumstances that appear to bring on the attack. The client should lie down in a darkened room, and avoid noise and movement when an attack occurs, if that is possible.
A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the physician in the emergency department. After completing ordered diagnostic tests, the physician indicates to the client what caused the symptoms that brought him to the hospital. What is the origin of the client's symptoms? a) Hypertension b) Cardiac disease c) Diabetes insipidus d) Impaired cerebral circulation
Impaired cerebral circulation TIAs result from impaired blood circulation in the brain, which can be caused by atherosclerosis and arteriosclerosis, cardiac disease, or diabetes. The symptoms of a TIA are the result of impaired blood circulation in the brain, which may have been caused by cardiac disease. The symptoms of a TIA are the result of impaired blood circulation in the brain, which may have been caused by diabetes. The symptoms of a TIA are the result of impaired blood circulation in the brain, which may have been caused by hypertension.
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? a) Elevated blood pressure b) Decreased level of consciousness (LOC) c) Increased urine output d) Decreased heart rate
Increased urine output The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output. A decreased LOC and elevated blood pressure may indicate lack of therapeutic effectiveness. A decreased heart rate doesn't indicate that mannitol is effective.
Which is a contraindication for the administration of tissue plasminogen activator (t-PA)? -Systolic blood pressure less than or equal to 185 mm Hg -Intracranial hemorrhage -Ischemic stroke -Age 18 years or older
Intracranial hemorrhage Intracranial hemorrhage, neoplasm, and aneurysm are contraindications for t-PA. Clinical diagnosis of ischemic stroke, age 18 years or older, and a systolic blood pressure less than or equal to 185 mm Hg are eligibility criteria.
A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention? a) Maintaining the client in a quiet environment b) Positioning the client to prevent airway obstruction c) Keeping the client in one position to decrease bleeding d) Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess
Keeping the client in one position to decrease bleeding The student nurse shouldn't keep the client in one position. 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 rebleeding.
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? a) Limited attention span and forgetfulness b) Visual agnosia c) Auditory agnosia d) Lack of deep tendon reflexes
Lack of deep tendon reflexes Damage to the occipital lobe can result in visual agnosia, whereas 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. Damage to the lower motor neurons may cause decreased muscle tone, flaccid muscle paralysis, and a decrease in or loss of reflexes.
A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings?
Left-sided cerebrovascular accident (CVA) When the infarct is on the left side of the brain, the symptoms are likely to be on the right, and the speech is more likely to be involved. If the MRI reveals an infarct, TIA is no longer the diagnosis. There is not enough information to determine if the stroke is still evolving or is complete.
A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings? a) Left-sided cerebrovascular accident (CVA) b) Completed Stroke c) Transient ischemic attack (TIA) d) Right-sided cerebrovascular accident (CVA)
Left-sided cerebrovascular accident (CVA) When the infarct is on the left side of the brain, the symptoms are likely to be on the right, and the speech is more likely to be involved. If the MRI reveals an infarct, TIA is no longer the diagnosis. There is not enough information to determine if the stroke is still evolving or is complete.
A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings? a) Left-sided cerebrovascular accident (CVA) b) Right-sided cerebrovascular accident (CVA) c) Transient ischemic attack (TIA) d) Completed Stroke
Left-sided cerebrovascular accident (CVA) When the infarct is on the left side of the brain, the symptoms are likely to be on the right, and the speech is more likely to be involved. If the MRI reveals an infarct, TIA is no longer the diagnosis. There is not enough information to determine if the stroke is still evolving or is complete.
A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem? -Pregabalin (Lyrica) -Diphenhydramine (Benadryl) -Heparin -Lioresal (Baclofen)
Lioresal (Baclofen) Spasticity, particularly in the hand, can be a disabling complication after stroke. Botulinum toxin type A injected intramuscularly into wrist and finger muscles has been shown to be effective in reducing this spasticity (although the effect is temporary, typically lasting 2 to 4 months) (Teasell, Foley, Pereira, et al., 2012). Other treatments for spasticity may include stretching, splinting, and oral medications such as baclofen (Lioresal).
A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem? a) Pregabalin (Lyrica) b) Diphenhydramine (Benadryl) c) Heparin d) Lioresal (Baclofen)
Lioresal (Baclofen) Spasticity, particularly in the hand, can be a disabling complication after stroke. Botulinum toxin type A injected intramuscularly into wrist and finger muscles has been shown to be effective in reducing this spasticity (although the effect is temporary, typically lasting 2 to 4 months) (Teasell, Foley, Pereira, et al., 2012). Other treatments for spasticity may include stretching, splinting, and oral medications such as baclofen (Lioresal). (less)
Which of the following is accurate regarding a hemorrhagic stroke? a) It is caused by a large-artery thrombosis. b) One of the main presenting symptoms is numbness or weakness of the face. c) Main presenting symptom is an "exploding headache." d) Functional recovery usually plateaus at 6 months.
Main presenting symptom is an "exploding headache." One of hemorrhagic stroke's main presenting symptom is an "exploding headache." In ischemic stroke, functional recovery usually plateaus at 6 months; it may be caused by a large artery thrombosis and may have a presenting symptoms of numbness or weakness of the face
A patient is brought to the emergency department with a possible stroke. What initial diagnostic test for a stroke, usually performed in the emergency department, would the nurse prepare the patient for?
Noncontrast computed tomogram The initial diagnostic test for a stroke is usually a noncontrast computed tomography (CT) scan. This should be performed within 25 minutes or less from the time the patient presents to the emergency department (ED) to determine if the event is ischemic or hemorrhagic (the category of stroke determines treatment).
A client with a cerebrovascular accident (CVA) is having difficulty with eating food on the plate. Which is the best nursing action to be taken? a) Reposition the tray and plate. b) Perform a vision field assessment. c) Know this is a normal finding for CVA. d) Assist the client with feeding.
Perform a vision field assessment. The nurse should perform a vision field assessment to evaluate the client forhemianopia. This finding could indicate damage to the visual area of the brain as a result of evolving CVA. Repositioning the tray and assisting with feeding would not be the best nursing action until new finding has been evaluated. Hemianopia can be associated with a CVA but, when presenting as a new finding, should be evaluated and reported immediately. (less)
The nurse is caring for a patient with dysphagia. Which of the following interventions would be contraindicated while caring for this patient? a) Allowing ample time to eat b) Assisting the patient with meals c) Testing the gag reflex prior to offering food or fluids d) Placing food on the affected side of mouth
Placing food on the affected side of mouth 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.
The nurse is providing diet-related advice to a male patient following a cerebrovascular accident (CVA). The patient wants to minimize the volume of food and yet meet all nutritional elements. Which of the following suggestions should the nurse give to the patient about controlling the volume of food intake? a) Provide a high-fat diet. b) Include dry or crisp foods and chewy meats. c) Always serve hot or tepid foods. d) Provide thickened commercial beverages and fortified cooked cereals.
Provide thickened commercial beverages and fortified cooked cereals. Patients with CVA or other cerebrovascular disorders should lose weight and therefore should minimize their volume of food consumption. To ensure this, the nurse may provide thickened commercial beverages, fortified cooked cereals, or scrambled eggs. Patients should avoid eating high-fat foods, and serving foods hot or tepid will not minimize the volume consumed by the patient. Foods such as peanut butter, bread, tart foods, dry or crisp foods, and chewy meats should also be avoided because they cause choking.
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? -Ineffective coping -Noncompliance -Risk for injury -Diarrhea
Risk for injury Because of decreased physical mobility, a client with recent left-sided hemiparesis is at risk for falls in the home setting. His ability to cope with the stroke is important, but investigating the home environment doesn't provide information about this nursing diagnosis. Diarrhea and Noncompliance aren't related to the client's home environment.
While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are: a) Footdrop and external hip rotation b) Severe headache and early change in level of consciousness c) Confusion or change in mental status d) Weakness on one side of the body and difficulty with speech
Severe headache and early change in level of consciousness The main presenting symptoms for ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body, confusion or change in mental status, and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Footdrop and external hip rotation can occur if a stroke victim is not turned or positioned correctly. (less)
While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are: a) Footdrop and external hip rotation b) Severe headache and early change in level of consciousness c) Weakness on one side of the body and difficulty with speech d) Confusion or change in mental status
Severe headache and early change in level of consciousness The main presenting symptoms for ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body, confusion or change in mental status, and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Footdrop and external hip rotation can occur if a stroke victim is not turned or positioned correctly. (less)
An emergency department nurse is interviewing a client with signs of an ischemic stroke that began 2 hours ago. The client reports that she had a cholecystectomy 6 weeks ago and is taking digoxin, coumadin, and labetelol. This client is not eligible for thrombolytic therapy for which of the following reasons? a) She is not within the treatment time window. b) She had surgery 6 weeks ago. c) She is taking digoxin. d) She is taking coumadin.
She is taking coumadin. 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. Digoxin and labetelol do not prohibit thrombolytic therapy.
A client is hospitalized when presenting to the emergency department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to his presymptomatic state. The nurse caring for the client knows that 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. 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. The symptoms do not describe a left- or right-sided stroke or a cerebral aneurysm.
A client is hospitalized when they present to the Emergency Department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to their presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what? a) Cerebral aneurysm b) Transient ischemic attack c) Left-sided stroke d) Right-sided stroke
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. 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. The symptoms do not describe a left- or right-sided stroke or a cerebral aneurysm.
The nurse is providing information about strokes to a community group. Which of the following would the nurse identify as the primary initial symptoms of an ischemic stroke? -Weakness on one side of the body and difficulty with speech -Footdrop and external hip rotation -Severe headache and early change in level of consciousness -Vomiting and seizures
Weakness on one side of the body and difficulty with speech The main presenting symptoms for an ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body; confusion or change in mental status; and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Footdrop and external hip rotation are things that can occur if a stroke victim is not turned or positioned correctly.
aneurysm
a weakening or bulge in an arterial wall
A 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 an artery leading to the brain. What is the term for the auscultated discovery?
bruit A neurologic examination during an attack reveals neurologic deficits. Auscultation of the artery may reveal a bruit (abnormal sound caused by blood flowing over a rough surface within one or both carotid arteries). The term for the auscultated discovery is "bruit."
A client's spouse relates how the client reported a severe headache and then was unable to talk or move their right arm and leg. After diagnostics are completed and the client is admitted to the hospital, when would basic rehabilitation begin? -in 2 to 3 days -immediately -after 1 week -upon transfer to a rehabilitation unit
immediately Beginning basic rehabilitation during the acute phase is an important nursing function. Measures such as position changes and prevention of skin breakdown and contractures are essential aspects of care during the early phase of rehabilitation. The nursing goal is to prevent complications that may interfere with the client's potential to recover function.
expressive aphasia
inability to express oneself; often associated with damage to the left frontal lobe area
Apraxia
inability to perform previously learned purposeful motor acts on a voluntary basis
A nurse in a rehabilitation facility is coordinating the discharge of a client who is tetraplegic. The client, who is married and has two children in high school, is being discharged to home and will require much assistance. Who would the discharge planner recognize as being the most important member of this client's care team?
spouse The client's spouse and family would need to be involved in the everyday care of the client; without their support, it is unlikely that the client would be able to manage at home.
A client is experiencing severe pain related to increased ICP. Which analgesic would be ordered for this client to help alleviate pain? 1. hydrocodone 2. morphine 3. fentanyl 4. codeine
4. codeine Avoid administering opioid analgesics, except codeine. Opioids interfere with accurate assessment of neurologic function because they constrict the pupils and depress LOC.
A patient diagnosed with a stroke is ordered to receive warfarin (Coumadin). Later, the nurse learns that the warfarin is contraindicated and the order is canceled. The nurse knows that the best alternative medication to give is which of the following? a) Ticlodipine (Ticlid) b) Dipyridamole (Persantine) c) Clopidogrel (Plavix) d) Aspirin
Aspirin If warfarin is contraindicated, aspirin is the best option, although other medications may be used if both are contraindicated.
A 73-year-old client is visiting the neurologist. The 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 an artery leading to the brain. What is the term for the auscultated discovery? a) Atherosclerotic plaque b) TIA c) Diplopia d) Bruit
Bruit A neurologic examination during an attack reveals neurologic deficits. Auscultation of the artery may reveal a bruit (abnormal sound caused by blood flowing over a rough surface within one or both carotid arteries). The term for the auscultated discovery is bruit.
An emergency department nurse is interviewing a client with signs of an ischemic stroke that began 2 hours ago. The client reports that she had a cholecystectomy 6 weeks ago and is taking digoxin, coumadin, and labetelol. This client is not eligible for thrombolytic therapy for which of the following reasons?
She is taking coumadin. 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. Digoxin and labetelol do not prohibit thrombolytic therapy.
dysarthria
defects of articulation due to neurologic causes
dysphagia
difficulty swallowing
receptive aphasia
inability to understand what someone else is saying; often associated with damage to the temporal lobe area
agnosia
loss of ability to recognize objects through a particular sensory system; may be visual, auditory, or tactile
hemiplegia
paralysis of one side of the body, or part of it, due to an injury in the motor area of the brain
When communicating with a client who has sensory (receptive) aphasia, the nurse should: a) speak loudly and articulate clearly. b) allow time for the client to respond. c) give the client a writing pad. d) use short, simple sentences.
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. Allowing time for the client to respond might be helpful but is less important than simplifying the communication. Because the client's hearing isn't affected, speaking loudly isn't necessary. A writing pad is helpful for clients with expressive, not receptive, aphasia.
A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings? 1. Completed Stroke 2. Right-sided cerebrovascular accident (CVA) 3. Left-sided cerebrovascular accident (CVA) 4. Transient ischemic attack (TIA)
3. Left-sided cerebrovascular accident (CVA) When the infarct is on the left side of the brain, the symptoms are likely to be on the right, and the speech is more likely to be involved. If the MRI reveals an infarct, TIA is no longer the diagnosis. There is not enough information to determine if the stroke is still evolving or is complete.
A patient has been diagnosed as having global aphasia. The nurse recognizes that the patient will be unable to do which of the following actions? a) Form words that are understandable b) Speak at all c) Form words that are understandable or comprehend the spoken word d) Comprehend the spoken word
Form words that are understandable or comprehend the spoken word Global aphasia is a combination of expressive and receptive aphasia and presents tremendous challenge to the nurse to effectively communicate with the patient. In receptive aphasia, the patient is unable to form words that are understandable. In expressive aphasia, the patient is unable to form words that are understandable. The patient who is unable to speak at all is referred to as mute.
A nurse is caring for a client who has returned to his room after a carotid endarterectomy. Which action should the nurse take first? a) Take the client's blood pressure. b) Ask the client if he has a headache. c) Ask the client if he has trouble breathing. d) Place antiembolism stockings on the client.
Ask the client if he has trouble breathing. The nurse should first assess the client's breathing. A complication of a carotid endarterectomy is an incisional hematoma, which could compress the trachea causing breathing difficulty for the client. Although the other measures are important actions, they aren't the nurse's top priority.
The nurse is caring for a patient with a history of transient ischemic attacks (TIAs) and moderate carotid stenosis who has undergone a carotid endarterectomy. Which of the following postoperative findings would cause the nurse the most concern? a) Blood pressure (BP): 128/86 mm Hg b) Neck pain: 3/10 (0 to 10 pain scale) c) Mild neck edema d) Difficulty swallowing
Difficulty swallowing The patient's inability to swallow without difficulty would cause the nurse the most concern. Difficulty in swallowing, hoarseness or other signs of cranial nerve dysfunction must be assessed. The nurse focuses on assessment of the following cranial nerves: facial (VII), vagus (X), spinal accessory (XI), and hypoglossal (XII). Some edema in the neck after surgery is expected; however, extensive edema and hematoma formation can obstruct the airway. Emergency airway supplies, including those needed for a tracheostomy, must be available. The patient's neck pain and mild BP elevation need addressing but would not cause the nurse the most concern. Hypotension is avoided to prevent cerebral ischemia and thrombosis. Uncontrolled hypertension may precipitate cerebral hemorrhage, edema, hemorrhage at the surgical incision, or disruption of the arterial reconstruction.
A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention? a) Maintaining the client in a quiet environment b) Keeping the client in one position to decrease bleeding c) Positioning the client to prevent airway obstruction d) Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess
Keeping the client in one position to decrease bleeding The student nurse shouldn't keep the client in one position. 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 rebleeding.
The statements presented here match nursing interventions with nursing diagnoses. Which statements are true for a client with a stroke? Select all that apply.
-Impaired swallowing: Provide a pureed diet. -Disturbed sensory perception: Stand on the client's unaffected side. -Impaired verbal communication: Repeat words and instructions. A pureed diet is often prescribed for a client with impaired swallowing. Other interventions for this client may include a thickened liquid diet, use of the chin tuck technique, and sitting upright. The client may have disturbed sensory perception related to visual disturbances, so standing on the client's unaffected side will allow him or her to see the nurse. The client with impaired verbal communication may benefit from repetition of words or instructions. Other interventions include facing the client, establishing eye contact, using short phrases, using communication boards, decreasing background noise, and allowing the client time between phrases to understand the information. For impaired physical mobility, instruct the client on the use of a walker to improve mobility. The client may experience weakness and the use of the walker will assist with ambulation. For self-care deficit, wide-grip utensils help the client to eat independently, addressing the self-care deficit related to nutrition and self-feeding.
The nurse is taking care of a client with a headache. In addition to administering medications, the nurse takes which measure to assist the client in reducing the pain associated with the headache? 1. Apply warm or cool cloths to the forehead or back of the neck. 2. Maintain hydration by drinking eight glasses of fluid a day. 3. Use pressure-relieving pads or a similar type of mattress. 4. Perform the Heimlich maneuver.
1. Apply warm or cool cloths to the forehead or back of the neck. Warmth promotes vasodilation; cool stimuli reduce blood flow.
An emergency department nurse is awaiting the arrival of a client with signs of an ischemic stroke that began 1 hour ago, as reported by emergency medical personnel. The treatment window for thrombolytic therapy is which of the following? 1. Two hours 2. Three hours 3. One hour 4. Six hours
2. Three hours Rapid diagnosis of stroke and initiation of thrombolytic therapy (within 3 hours) in clients with ischemic stroke leads to a decrease in the size of the stroke and an overall improvement in functional outcome after 3 months.
A nurse is teaching a community class that those experiencing symptoms of ischemic stroke need to enter the medical system early. The primary reason for this is which of the following? 1. A ruptured arteriovenous malformation will cause deficits until it is stopped. 2. Thrombolytic therapy has a time window of only 3 hours. 3. A ruptured intracranial aneurysm must quickly be repaired. 4. Intracranial pressure is increased by a space-occupying bleed.
2. Thrombolytic therapy has a time window of only 3 hours. Currently approved thrombolytic therapy for ischemic strokes has a treatment window of only 3 hours after the onset of symptoms. Urgency is needed on the part of the public for rapid entry into the medical system. The other three choices are related to hemorrhagic strokes.
An emergency department nurse understands that a 110-lb (50-kg) recent stroke victim will receive at least the minimum dose of recombinant tissue plasminogen activator (t-PA). What minimum dose will the client receive? -50 mg -85 mg -45 mg -90 mg
45 mg The client is weighed to determine the dose of t-PA. Typically, two or more IV sites are established prior to administration of t-PA (one for the t-PA and the other for administration of IV fluids). The dosage for t-PA is 0.9 mg/kg, with a maximum dose of 90 mg. 50 kg X 0.9 mg= 45 mg dose
Which of the following statements reflect nursing management of the patient with expressive aphasia? a) Frequently reorient the patient to time, place, and situation b) Speak clearly to the patient in simple sentences, use gestures or pictures when able c) Speak slowly and clearly to assist the patient in forming the sounds d) Encourage the patient to repeat sounds of the alphabet
Encourage the patient to repeat sounds of the alphabet 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 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. (less)
The nurse is providing diet-related advice to a male patient following a cerebrovascular accident (CVA). The patient wants to minimize the volume of food and yet meet all nutritional elements. Which of the following suggestions should the nurse give to the patient about controlling the volume of food intake?
Provide thickened commercial beverages and fortified cooked cereals. Patients with CVA or other cerebrovascular disorders should lose weight and therefore should minimize their volume of food consumption. To ensure this, the nurse may provide thickened commercial beverages, fortified cooked cereals, or scrambled eggs. Patients should avoid eating high-fat foods, and serving foods hot or tepid will not minimize the volume consumed by the patient. Foods such as peanut butter, bread, tart foods, dry or crisp foods, and chewy meats should also be avoided because they cause choking.
Which of the following terms refer to the failure to recognize familiar objects perceived by the senses? a) Agnosia b) Perseveration c) Apraxia d) Agraphia
Agnosia Auditory agnosia is failure to recognize significance of sounds. 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.
A stroke victim is experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe?
Frontal 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 a lack of motivation.
hemiparesis
weakness of one side of the body, or part of it, due to an injury in the motor area of the brain
A client has a 12-year history of migraine headaches and is frustrated over how these headaches impact lifestyle. The nurse discusses the potential triggers of the client's migraines. Which is not a potential trigger to migraines? 1. seasonal changes 2. specific food chemicals 3. medications 4. reproductive hormone fluctuations
3. medications Researchers believe the contributing cofactors for the cause of migraines are from changes in serotonin receptors that promote dilation of cerebral blood vessels and pain intensification from neurochemicals released from the trigeminal nerve. It has been suggested that fluctuations in reproductive hormones, chemicals in certain foods, and medications can trigger migraines.
Which of the following is the most common side effect of tissue plasminogen activator (tPA)? -Increased intracranial pressure (ICP) -Hypertension -Headache -Bleeding
Bleeding Bleeding is the most common side effect of tPA. The patient is closely monitored for bleeding (at IV insertion sites, gums, urine/stools, and intracranially by assessing changes in level of consciousness). Headache, increased ICP, and hypertension are not side effects of tPA.
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? -Sexual history -Blood pressure and weight -Motor and sensory responses -Frequent neurologic checks
Frequent neurologic checks If the client undergoes carotid artery surgery, the nurse performs frequent neurologic checks to detect paralysis, confusion, facial asymmetry, or aphasia. Body weight is measured because obesity, hyperlipidemia, and atherosclerosis are related to cerebrovascular disease, and not in the case of carotid artery surgery. Sexual history and motor and sensory responses are not important assessments to be performed for such clients.
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 Explanation: Damage to the frontal lobe may impair learning capacity, memory, or other higher cortical intellectual functions. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and a lack of motivation. 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
Hemianopsia
blindness of half of the field of vision in one or both eyes
During a class on stroke, a junior nursing student asks what the clinical manifestations of stroke are. What would be the instructor's best answer? a) "Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation." b) "Clinical manifestations of a stroke generally include aphasia, one-sided flaccidity, and trouble swallowing." c) "Clinical manifestations of a stroke depend on how quickly the clot can be dissolved." d) "Clinical manifestations of a stroke are highly variable, depending on the cardiovascular health of the client."
"Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation." Clinical manifestations following a stroke are highly variable and depend on the area of the cerebral cortex and the affected hemisphere, the degree of blockage (total, partial), and the presence or absence of adequate collateral circulation. (Collateral circulation is circulation formed by smaller blood vessels branching off from or near larger occluded vessels.) 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.
A client undergoes cerebral angiography for evaluation after an intracranial computed tomography scan revealed a subarachnoid hemorrhage. Afterward, 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 (LOC) 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. Nausea, vomiting, and profuse sweating suggest a delayed reaction to the contrast medium used in cerebral angiography. Difficulty breathing or swallowing may signal a hematoma in the neck. Tachycardia, tachypnea, and hypotension suggest internal hemorrhage.
A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to perform which action? 1. Form words that are understandable or comprehend spoken words 2. Comprehend spoken words 3. Speak at all 4. Form words that are understandable
1. Form words that are understandable or comprehend spoken words Global aphasia is a combination of expressive and receptive aphasia and presents a tremendous challenge to the nurse to effectively communicate with the client. In receptive and expressive aphasia, the client is unable to form words that are understandable. The client who is unable to speak at all is referred to as mute.
A client is experiencing dysphagia following a stroke. Which measure may be taken by the nurse to ensure that the client's diet allows for easy swallowing? 1. Help the client sit upright when eating and feed slowly. 2. Instruct the client to lie on the bed when eating. 3. Allow optimum physical activity before meals to expedite digestion. 4. Offer liquids frequently and in large quantities.
1. Help the client sit upright when eating and feed slowly. Having the client sit upright, preferably out of bed in a chair, and instructing him or her to tuck the chin toward the chest when swallowing will help prevent aspiration. The client may be started on a thick liquid or puréed diet, because these foods are easier to swallow than thin liquids. The diet may be advanced as the client becomes more proficient at swallowing. If the client cannot resume oral intake, a gastrointestinal feeding tube is placed for ongoing tube feedings and medication administration. The client should be allowed to rest before meals because fatigue may interfere with coordination and following instructions.
Which terms refers to blindness in the right or left half of the visual field in both eyes? 1. Scotoma 2. Nystagmus 3. Homonymous hemianopsia 4. Diplopia
3. Homonymous hemianopsia Homonymous hemianopsia occurs with occipital lobe tumors. 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 nurse is teaching a community class that those experiencing symptoms of ischemic stroke need to enter the medical system early. The primary reason for this is which of the following? 1. Intracranial pressure is increased by a space-occupying bleed. 2. A ruptured intracranial aneurysm must quickly be repaired. 3. Thrombolytic therapy has a time window of only 3 hours. 4. A ruptured arteriovenous malformation will cause deficits until it is stopped.
3. Thrombolytic therapy has a time window of only 3 hours. Currently approved thrombolytic therapy for ischemic strokes has a treatment window of only 3 hours after the onset of symptoms. Urgency is needed on the part of the public for rapid entry into the medical system. The other three choices are related to hemorrhagic strokes.
The nurse is caring for a patient with aphasia. Which of the following strategies will the nurse use to facilitate communication with the patient? a) Avoiding the use of hand gestures b) Establishing eye contact c) Speaking in complete sentences d) Speaking loudly
Establishing eye contact The following strategies should be used by the nurse to encourage communication with a patient with aphasia: face the patient and establish eye contact, speak in your usual manner and tone, use short phrases, and pause between phrases to allow the patient time to understand what is being said; limit conversation to practical and concrete matters; use gestures, pictures, objects, and writing; and as the patient uses and handles an object, say what the object is. It helps to match the words with the object or action, be consistent in using the same words and gestures each time you give instructions or ask a question, and keep extraneous noises and sounds to a minimum. Too much background noise can distract the patient or make it difficult to sort out the message being spoken. (less)
The nurse is providing information about strokes to a community group. Which of the following would the nurse identify as the primary initial symptoms of an ischemic stroke? a) Footdrop and external hip rotation b) Vomiting and seizures c) Severe headache and early change in level of consciousness d) Weakness on one side of the body and difficulty with speech
Weakness on one side of the body and difficulty with speech The main presenting symptoms for an ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body; confusion or change in mental status; and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Footdrop and external hip rotation are things that can occur if a stroke victim is not turned or positioned correctly.
A community health nurse is conducting a workshop for unlicensed care providers who work in a chain of long-term care facilities. The nurse is teaching the participants about the signs and symptoms of stroke. What signs and symptoms should the nurse identify? Select all that apply. -Visual disturbances -Sudden ear pain -Confusion -Sudden numbness -Epistaxis (nosebleed)
-Confusion -Sudden numbness -Visual disturbances The most common symptoms of stroke include numbness or weakness of the face, arm, or leg, especially on one side of the body; confusion or change in mental status; trouble speaking or understanding speech; visual disturbances; difficulty walking, dizziness, or loss of balance or coordination; and sudden, severe headache.
Which of the following is accurate regarding a hemorrhagic stroke? 1. It is caused by a large-artery thrombosis. 2. Main presenting symptom is an "exploding headache." 3. One of the main presenting symptoms is numbness or weakness of the face. 4. Functional recovery usually plateaus at 6 months.
2. Main presenting symptom is an "exploding headache." One of hemorrhagic stroke's main presenting symptom is an "exploding headache." In ischemic stroke, functional recovery usually plateaus at 6 months; it may be caused by a large artery thrombosis and may have a presenting symptoms of numbness or weakness of the face.
What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke? 1. Slow, cautious behavior 2. Aphasia 3. Altered intellectual ability 4. Left visual field deficit
4. Left visual field deficit A left visual field deficit is a common clinical manifestation of a right hemispheric stroke. Aphasia, slow, cautious behavior, and altered intellectual ability are all clinical manifestations of a left hemispheric stroke.
Which of the following is a contraindication for the administration of tissue plasminogen activator (t-PA)? a) Systolic blood pressure less than or equal to 185 mm Hg b) Ischemic stroke c) Intracranial hemorrhage d) Age 18 years of age or older
Intracranial hemorrhage Intracranial hemorrhage, neoplasm, or aneurysm is a contraindication to t-PA. Clinical diagnosis of ischemic stroke, age 18 years of age or older, and a systolic BP less than or equal to 185 mm Hg are eligibility criteria. (less)
While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are:
Severe headache and early change in level of consciousness The main presenting symptoms for ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body, confusion or change in mental status, and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Footdrop and external hip rotation can occur if a stroke victim is not turned or positioned correctly.
