Chapter 47: Nursing Management: Patients With Cerebrovascular Disorders
A 72-year-old woman is being treated on a medical unit 1 week after experiencing an ischemic stroke. The effects of the woman's stroke include slurred, partially intelligible speech. However, the patient's comprehension of spoken language remains intact. The nurse should expect to read documentation in the patient's chart of: A) Dysarthria B) Aphasia C) Dysphasia D) Apraxia
A) Dysarthria
What should be included in the patients care plan when establishing an exercise program for a patient affected by a stroke? A) Schedule passive range of motion every other day. B) Keep activity limited, as the patient may be over stimulated. C) Have the patient perform active range-of-motion (ROM) exercises once a day. D) Exercise the affected extremities passively four or five times a day.
Ans: D Feedback: The affected extremities are exercised passively and put through a full ROM four or five times a day to maintain joint mobility, regain motor control, prevent development of a contracture in the paralyzed extremity, prevent further deterioration of the neuromuscular system, and enhance circulation. Active ROM exercises should ideally be performed more than once per day.
A 77-year-old man is receiving care in the neurological intensive care unit following an ischemic stroke. The patient is breathing spontaneously but has not yet regained consciousness. How should the nurses in the neuro ICU best position this patient? A) In the high Fowler's position with a pillow under his knees B) Side-lying with the head of the bed slightly elevated C) Supine with pillows supporting his extremities D) In the semi-Fowler's position
B) Side-lying with the head of the bed slightly elevated
Disturbed by the high incidence and poor outcomes of stroke in the community, a public health nurse is planning a health promotion campaign that is specifically focused on stroke. Which of the following proposed outcomes would most directly address an identified public awareness need? A)"Participants will describe the factors that affect cerebral blood flow." B)"Participants will state the most common signs and symptoms of stroke." C) "Participants will state the common treatment modalities for different types of stroke." D) "Participants will describe the relationship between psychological stress and stroke."
B)"Participants will state the most common signs and symptoms of stroke."
A patient has been admitted to a unit at a primary stroke center after experiencing an ischemic stroke. The nurse on the unit is aware of the vital importance of rehabilitative efforts and knows that an active rehabilitation program should begin at what point? - As soon as the patient is able to independently identify goals for rehabilitation - As soon as moderate motor activity is regained on the affected side - As soon as sensory ability is regained on the affected side - As soon as the patient regains consciousness
Correct response: As soon as the patient regains consciousness Explanation: Usually an active rehabilitation program is started as soon as the patient regains consciousness. It would be erroneous to wait until the affected side recovers. Patients may benefit from rehabilitation before they are able to independently set goals.
A female patient who is recovering from a stroke has begun eating a minced and pureed diet after passing the speech pathologist's swallowing assessment. This morning, the nurse set up the patient with her breakfast tray and later noticed that the woman was swallowing her food well but dribbling small amounts of food out of affected side of her mouth. How should the nurse follow up this observation? - Provide oral suctioning after each bite that the patient swallows. - Remove the patient's tray because of the risk of aspiration. - Cue the patient to the fact that she is dribbling food while commending her for eating. - Make the patient NPO and encourage the care provider to consider enteral nutrition.
Correct response: Cue the patient to the fact that she is dribbling food while commending her for eating. Explanation: Dribbling of food should be noted and addressed but does not necessarily constitute an acute risk of aspiration. Close observation is warranted but enteral feeding and NPO status are not likely necessary. Suctioning after each bite of food is not necessary.
A patient admitted with a stroke is coming to the unit from the emergency department. The nurse assigned to care for the new patient knows that what assessment finding is indicative of a stroke? - Electrolyte imbalance - Difficulty speaking - Increase in heart rate - Facial edema
Correct response: Difficulty speaking Explanation: Difficulty speaking is a classic abnormal finding on a physical assessment that may be associated with a stroke. Tachycardia, edema, and electrolyte imbalances are not common initial presentations of stroke.
A nurse has developed a strong therapeutic rapport with a male patient during the patient's recovery in hospital from a stroke. The patient has had a largely successful recovery but has admitted to the nurse that he has concerns about how his sexual relationship will be affected upon discharge. The nurse should respond to the patient's statement by: - Encouraging him to focus on his achievements rather than his perceived deficits - Encouraging him to consider alternative forms of sexual expression with his partner - Encouraging him to prioritize the emotional aspects of his relationship rather than the physical aspects - Encouraging him with the fact that this aspect of his life is not likely to have been affected by his stroke
Correct response: Encouraging him to consider alternative forms of sexual expression with his partner Explanation: Encouraging the patient to explore alternative methods of sexual expression acknowledges the patient's concerns and provides a realistic and empathic response. It is inappropriate to divert the patient's concerns or to provide unrealistic expectations.
Which are contraindications for the administration of tissue plasminogen activator (t-PA)? Select all that apply. - Major abdominal surgery within 10 days - Age 18 years or older - Intracranial hemorrhage - Ischemic stroke - Systolic BP less than or equal to 185 mm Hg
Correct response: Intracranial hemorrhage Major abdominal surgery within 10 days Explanation: Intracranial hemorrhage, neoplasm, aneurysm, and major surgical procedures within 14 days are contraindications to t-PA. Clinical diagnosis of ischemic stroke, being 18 years of age or older, and a systolic BP less than or equal to 185 mm Hg are eligibility criteria.
A family member comes to the clinic to talk to the nurse about a client who has had a stroke on the right side of the brain. The family member is concerned because of the deficits the client is exhibiting. The nurse knows that when a client experiences a stroke on the right side of the brain, common deficits include what? Select all that apply. - Hyperaware of deficits - Impairment of long-term memory - Left-sided hemiplegia - Tendency to distractibility - Neglect of objects and people on the left side
Correct response: Left-sided hemiplegia Tendency to distractibility Neglect of objects and people on the left side Explanation: Left-sided hemiplegia (stroke on right side of brain) may have the following neurologic deficits: spatial-perceptual defects; disregard for the deficits of the affected side require special safety considerations; tendency to distractibility; impulsive behavior, unaware of deficits; poor judgment; defects in left visual fields; misjudge distances; difficulty distinguishing upside-down and right-side up; impairment of short-term memory; and neglect left side of body, objects and people on left side.
A patient has had an ischemic stroke and has been admitted to the unit. The nurse knows the importance of the principles of body alignment and correct positioning to stroke victims. How should the nurse position the patient to prevent joint deformities? - Place the patient flat in the prone position for 30 minutes per day. - Place patient's hand in pronation. - Place a pillow in the axilla when there is limited external rotation. - Assist the patient in acutely flexing the thigh to promote movement.
Correct response: Place a pillow in the axilla when there is limited external rotation. Explanation: A pillow in the axilla prevents adduction of the affected shoulder and keeps the arm away from the chest. The prone position with a pillow under the pelvis, not flat, promotes hyperextension of the hip joints, essential for normal gait. To promote venous return and prevent edema, the upper thigh should not be flexed acutely. The hand is placed in slight supination, not pronation, which is its most functional position.
After having a stroke, a patient has cognitive deficits. What are the cognitive deficits the nurse recognizes the patient has as a result of the stroke? Select all that apply. - Paresthesias - Expressive aphasia - Short- and long-term memory loss - Poor abstract reasoning - Decreased attention span
Correct response: Poor abstract reasoning Decreased attention span Short- and long-term memory loss Explanation: Cognitive deficits associated with stroke include short- and long-term memory loss, decreased attention span, and poor abstract reasoning. Expressive aphasia is a verbal deficit, not a cognitive deficit. Paresthesias are sensory deficits, not cognitive deficits.
A patient has severe shoulder pain from subluxation of the shoulder is being cared for on the unit. To prevent further injury and pain, the nurse caring for this patient is aware of what? - Passively exercising the affected extremity is avoided to minimize pain. - Use of a sling should be avoided due to adduction of the affected shoulder. - Elevation of the arm and hand can lead to further complications associated with edema. - The patient should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder.
Correct response: The patient should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder. Explanation: To prevent shoulder pain, the nurse should never lift a patient by the flaccid shoulder or pull on the affected arm or shoulder. The patient is taught how to move and exercise the affected arm/shoulder through proper movement and positioning. The use of a properly worn sling when the patient is out of bed prevents the paralyzed upper extremity from dangling without support. Range of motion exercises are still vitally important in preventing a frozen shoulder and ultimate atrophy of subcutaneous tissues, which can cause more pain. Elevation of the arm and hand is also important in preventing dependent edema of the hand.
A woman has been brought to the emergency department (ED) by her distraught husband who believes that she has had a stroke. A rapid assessment by the care team confirms that the husband's suspicions are likely accurate, and the woman is being screened for the possible administration of recombinant tissue plasminogen activator (r tPA). Which of the following factors would contraindicate the use of tPA? - The woman has hypertension and type 1 diabetes. - The woman has previously had a stroke. - The woman's stroke has a hemorrhagic etiology. - The woman is older than 80 years of age.
Correct response: The woman's stroke has a hemorrhagic etiology. Explanation: tPA is contraindicated in hemorrhagic stroke because it would greatly exacerbate cerebral bleeding. Older age, previous stroke, hypertension, and diabetes do not necessarily contraindicate the use of tPA.
Nurses on a neurological unit have been conscientious about positioning a patient to maximize mobility and preserve function following the patient's stroke 2 weeks ago. How should the patient's hands be best positioned to meet these goals? - With her hands slightly flexed and her palms facing up - With her fists closed and her wrists in a neutral position - With her wrists flexed and fingers straight - With her fingers straight and her palms facing down
Correct response: With her hands slightly flexed and her palms facing up Explanation: The fingers are positioned so that they are barely flexed. The hand is placed in slight supination (palm faces upward), which is its most functional position.
A nurse is caring for a patient diagnosed with a hemorrhagic stroke. When creating this patients plan of care, what goal should be prioritized? A) Prevent complications of immobility. B) Maintain and improve cerebral tissue perfusion. C) Relieve anxiety and pain. D) Relieve sensory deprivation.
Ans: B Feedback: Each of the listed goals is appropriate in the care of a patient recovering from a stroke. However, promoting cerebral perfusion is a priority physiologic need, on which the patients survival depends.
A nurse who provides care at a community clinic is in contact with a diverse group of patients. Which of the following individuals most clearly displays risk factors for stroke? - An obese woman with a history of atrial fibrillation and type 2 diabetes - A man who is receiving oral antibiotics for the treatment of a chlamydial infection - A woman who has osteoporosis, a history of fractures, and a family history of stroke - A 70-year-old man who has benign prostatic hyperplasia and early stage Alzheimer's disease
Correct response: An obese woman with a history of atrial fibrillation and type 2 diabetes Explanation: Obesity, atrial fibrillation, and type 2 diabetes are all highly significant risk factors for stroke. None of the other listed individuals displays multiple risk factors for stroke.
A 76-year-old male client is brought to the clinic by his daughter. The daughter states that her father has had two transient ischemic attacks (TIAs) in the past week. The physician orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option does the nurse expect the physician to offer this client to increase blood flow to the brain? Select all that apply. - Percutaneous transluminal coronary artery angioplasty - Carotid endarterectomy - Administration of tissue plasminogen activator - Removal of the carotid artery - Balloon angioplasty of the carotid artery followed by stent placement
Correct response: Balloon angioplasty of the carotid artery followed by stent placement Carotid endarterectomy Explanation: If narrowing of the carotid artery by atherosclerotic plaques is the cause of the TIAs, a carotid endarterectomy (surgical removal of atherosclerotic plaque) could be performed. A balloon angioplasty of the carotid artery, a procedure similar to a percutaneous transluminal coronary artery angioplasty, may be performed alternatively to dilate the carotid artery and increase blood flow to the brain, followed by stent placement. The other options are not options to increase blood flow through the carotid artery to the brain.
When preparing to discharge a patient home, the nurse has met with the family and warned them that the patient may exhibit unexpected emotional responses. The nurse should teach the family that these responses are typically a result of what cause? A) Frustration around changes in function and communication B) Unmet physiologic needs C) Changes in brain activity during sleep and wakefulness D) Temporary changes in metabolism
Ans: A Feedback: Emotional problems associated with stroke are often related to the new challenges around ADLs and communication. These challenges are more likely than metabolic changes, unmet physiologic needs, or changes in brain activity, each of which should be ruled out.
The nurse is assessing a patient with a suspected stroke. What assessment finding is most suggestive of a stroke? A) Facial droop B) Dysrhythmias C) Periorbital edema D) Projectile vomiting
Ans: A Feedback: Facial drooping or asymmetry is a classic abnormal finding on a physical assessment that may be associated with a stroke. Facial edema is not suggestive of a stroke and patients less commonly experience dysrhythmias or vomiting.
A patient who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurses care of this patient? A) The patient should be approached on the side where visual perception is intact. B) Attention to the affected side should be minimized in order to decrease anxiety. C) The patient should avoid turning in the direction of the defective visual field to minimize shoulder subluxation. D) The patient should be approached on the opposite side of where the visual perception is intact to promote recovery.
Ans: A Feedback: Patients with decreased field of vision should first be approached on the side where visual perception is intact. All visual stimuli should be placed on this side. The patient can and should be taught to turn the head in the direction of the defective visual field to compensate for this loss. The nurse should constantly remind the patient of the other side of the body and should later stand at a position that encourages the patient to move or turn to visualize who and what is in the room.
The patient has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the patients atmosphere more conducive to communication? A) Provide a board of commonly used needs and phrases. B) Have the patient speak to loved ones on the phone daily. C) Help the patient complete his or her sentences. D) Speak in a loud and deliberate voice to the patient.
Ans: A Feedback: The inability to talk on the telephone or answer a question or exclusion from conversation causes anger, frustration, fear of the future, and hopelessness. A common pitfall is for the nurse or other health care team member to complete the thoughts or sentences of the patient. This should be avoided because it may cause the patient to feel more frustrated at not being allowed to speak and may deter efforts to practice putting thoughts together and completing a sentence. The patient may also benefit from a communication board, which has pictures of commonly requested needs and phrases. The board may be translated into several languages.
A patient is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this patient is aware that an absolute contraindication for thrombolytic therapy is what? A) Evidence of hemorrhagic stroke B) Blood pressure of 180/110 mm Hg C) Evidence of stroke evolution D) Previous thrombolytic therapy within the past 12 months
Ans: A Feedback: Thrombolytic therapy would exacerbate a hemorrhagic stroke with potentially fatal consequences. Stroke evolution, high BP, or previous thrombolytic therapy does not contraindicate its safe and effective use.
A preceptor is discussing stroke with a new nurse on the unit. The preceptor would tell the new nurse which cardiac dysrhythmia is associated with cardiogenic embolic strokes? A) Ventricular tachycardia B) Atrial fibrillation C) Supraventricular tachycardia D) Bundle branch block
Ans: B Feedback: Cardiogenic embolic strokes are associated with cardiac dysrhythmias, usually atrial fibrillation. The other listed dysrhythmias are less commonly associated with this type of stroke.
A patient has recently begun mobilizing during the recovery from an ischemic stroke. To protect the patients safety during mobilization, the nurse should perform what action? A) Support the patients full body weight with a waist belt during ambulation. B) Have a colleague follow the patient closely with a wheelchair. C) Avoid mobilizing the patient in the early morning or late evening. D) Ensure that the patients family members do not participate in mobilization.
Ans: B Feedback: During mobilization, a chair or wheelchair should be readily available in case the patient suddenly becomes fatigued or feels dizzy. The family should be encouraged to participate, as appropriate, and the nurse should not have to support the patients full body weight. Morning and evening activity are not necessarily problematic.
When caring for a patient who has had a stroke, a priority is reduction of ICP. What patient position is most consistent with this goal? A) Head turned slightly to the right side B) Elevation of the head of the bed C) Position changes every 15 minutes while awake D) Extension of the neck
Ans: B Feedback: Elevation of the head of the bed promotes venous drainage and lowers ICP, the nurse should avoid flexing or extending the neck or turning the head side to side. The head should be in a neutral midline position. Excessively frequent position changes are unnecessary.
A family member brings the patient to the clinic for a follow-up visit after a stroke. The family member asks the nurse what he can do to decrease his chance of having another stroke. What would be the nurses best answer? A) Have your heart checked regularly. B) Stop smoking as soon as possible. C) Get medication to bring down your sodium levels. D) Eat a nutritious diet.
Ans: B Feedback: Smoking is a modifiable and highly significant risk factor for stroke. The significance of smoking, and the potential benefits of quitting, exceed the roles of sodium, diet, and regular medical assessments.
The nurse is discharging home a patient who suffered a stroke. He has a flaccid right arm and leg and is experiencing problems with urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common patient response to a change in body image? A) Denial B) Fear C) Depression D) Disassociation
Ans: C Feedback: Depression is a common and serious problem in the patient who has had a stroke. It can result from a profound disruption in his or her life and changes in total function, leaving the patient with a loss of independence. The nurse needs to encourage the patient to verbalize feelings to assess the effect of the stroke on self-esteem. Denial, fear, and disassociation are not the most common patient response to a change in body image, although each can occur in some patients.
The nurse is reviewing the medication administration record of a female patient who possesses numerous risk factors for stroke. Which of the womans medications carries the greatest potential for reducing her risk of stroke? A) Naproxen 250 PO b.i.d. B) Calcium carbonate 1,000 mg PO b.i.d. C) Aspirin 81 mg PO o.d. D) Lorazepam 1 mg SL b.i.d. PRN
Ans: C Feedback: Research findings suggest that low-dose aspirin may lower the risk of stroke in women who are at risk. Naproxen, lorazepam, and calcium supplements do not have this effect.
The pathophysiology of an ischemic stroke involves the ischemic cascade, which includes the following steps: 1. Change in pH 2. Blood flow decreases 3. A switch to anaerobic respiration 4. Membrane pumps fail 5. Cells cease to function 6. Lactic acid is generated Put these steps in order in which they occur. A) 635241 B) 352416 C) 236145 D) 162534
Ans: C Feedback: The ischemic cascade begins when cerebral blood flow decreases to less than 25 mL per 100 g of blood per minute. At this point, neurons are no longer able to maintain aerobic respiration. The mitochondria must then switch to anaerobic respiration, which generates large amounts of lactic acid, causing a change in the pH. This switch to the less efficient anaerobic respiration also renders the neuron incapable of producing sufficient quantities of adenosine triphosphate (ATP) to fuel the depolarization processes. The membrane pumps that maintain electrolyte balances begin to fail, and the cells cease to function.
The nurse is preparing health education for a patient who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in this education? A) Mild, intermittent seizures can be expected. B) Take ibuprofen for complaints of a serious headache. C) Take antihypertensive medication as ordered. D) Drowsiness is normal for the first week after discharge.
Ans: C Feedback: The patient and family are provided with information that will enable them to cooperate with the care and restrictions required during the acute phase of hemorrhagic stroke and to prepare the patient to return home. Patient and family teaching includes information about the causes of hemorrhagic stroke and its possible consequences. Symptoms of hydrocephalus include gradual onset of drowsiness and behavioral changes. Hypertension is the most serious risk factor, suggesting that appropriate antihypertensive treatment is essential for a patient being discharged. Seizure activity is not normal, complaints of a serious headache should be reported to the physician before any medication is taken. Drowsiness is not normal or expected.
A patient diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse? A) Sit with the patient for a few minutes. B) Administer an analgesic. C) Inform the nurse-manager. D) Call the physician immediately.
Ans: D Feedback: A headache may be an indication that the aneurysm is leaking. The nurse should notify the physician immediately. The physician will decide whether administration of an analgesic is indicated. Informing the nurse-manager is not necessary. Sitting with the patient is appropriate, once the physician has been notified of the change in the patients condition.
A nurse in the ICU is providing care for a patient who has been admitted with a hemorrhagic stroke. The nurse is performing frequent neurologic assessments and observes that the patient is becoming progressively more drowsy over the course of the day. What is the nurses best response to this assessment finding? A) Report this finding to the physician as an indication of decreased metabolism. B) Provide more stimulation to the patient and monitor the patient closely. C) Recognize this as the expected clinical course of a hemorrhagic stroke. D) Report this to the physician as a possible sign of clinical deterioration.
Ans: D Feedback: Alteration in LOC often is the earliest sign of deterioration in a patient with a hemorrhagic stroke. Drowsiness and slight slurring of speech may be early signs that the LOC is deteriorating. This finding is unlikely to be the result of metabolic changes and it is not expected. Stimulating a patient with an acute stroke is usually contraindicated.
A nursing student is writing a care plan for a newly admitted patient who has been diagnosed with a stroke. What major nursing diagnosis should most likely be included in the patients plan of care? A) Adult failure to thrive B) Post-trauma syndrome C) Hyperthermia D) Disturbed sensory perception
Ans: D Feedback: The patient who has experienced a stroke is at a high risk for disturbed sensory perception. Stroke is associated with multiple other nursing diagnoses, but hyperthermia, adult failure to thrive, and post- trauma syndrome are not among these.
A female patient is diagnosed with a right-sided stroke. The patient is now experiencing hemianopsia. How might the nurse help the patient manage her potential sensory and perceptional difficulties? A) Keep the lighting in the patients room low. B) Place the patients clock on the affected side. C) Approach the patient on the side where vision is impaired. D) Place the patients extremities where she can see them.
Ans: D Feedback: The patient with homonymous hemianopsia (loss of half of the visual field) turns away from the affected side of the body and tends to neglect that side and the space on that side, this is called amorphosynthesis. In such instances, the patient cannot see food on half of the tray, and only half of the room is visible. It is important for the nurse to remind the patient constantly of the other side of the body, to maintain alignment of the extremities, and if possible, to place the extremities where the patient can see them. Patients with a decreased field of vision should be approached on the side where visual perception is intact. All visual stimuli (clock, calendar, and television) should be placed on this side. The patient can be taught to turn the head in the direction of the defective visual field to compensate for this loss. Increasing the natural or artificial lighting in the room and providing eyeglasses are important in increasing vision. There is no reason to keep the lights dim.
A patient's recent stroke has had a profound effect on his communication. To foster an atmosphere that is conducive to communication and the recovery of speech the nurse should: A)Speak to the patient using simplified vocabulary and short sentences. B) Disregard the patient's gestures in an effort to encourage speech. C) Adhere to predictable schedules whenever possible. D) Ensure that the patient receives constant stimulation during daytime hours.
C) Adhere to predictable schedules whenever possible.
A patient has been undergoing rehabilitation for the past 3 weeks following a hemorrhagic stroke. The nurse has observed that the patient is motivated to perform his activities of daily living independently, but rarely attempts tasks with his affected arm. How should the nurse address this observation with the patient? - "You should be doing a lot more with your affected arm and a lot less with your strong arm." - "Even though it requires a huge effort, using your affected arm will help you build its strength." - "I've noticed that you're being very conscientious about protecting your affected arm, which is very important." - "If you don't push through the challenge of using your affected arm again it might never recover."
Correct response: "Even though it requires a huge effort, using your affected arm will help you build its strength." Explanation: The nurse must be sure that the patient does not neglect the affected side. However, this must be communicated in an empathic and nonthreatening way.
The nurse is preparing to administer tissue plasminogen activator (t-PA) to a patient who weighs 132 lb. The order reads 0.9 mg/kg t-PA. The nurse understands that 10% of the calculated dose is administered as an IV bolus over 1 minute, and the remaining dose (90%) is administered IV over 1 hour via an infusion pump. How many milligrams IV bolus over 1 minute will the nurse initially administer?
Correct response: 5.4 Explanation: The patient 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. Of the calculated dose, 10% is administered as an IV bolus over 1 minute. The remaining dose (90%) is administered IV over 1 hour via an infusion pump. First, the nurse must convert the patient's weight to kilograms (132/2.2 = 60 kg), then multiply 0.9 mg × 60 kg = 54 mg. Next, the nurse figure out that 10% of 54 mg is 5.4 (54 ×.10). The nurse will initially administer 5.4 mgs IV bolus over 1 minute.
When caring for a patient who has had a hemorrhagic stroke, close monitoring of vital signs and neurological status is imperative. What is the earliest sign of deterioration in a patient with a hemorrhagic stroke? - Shortness of breath - Alteration in level of consciousness (LOC) - Headache - Tonic-clonic seizures
Correct response: Alteration in level of consciousness (LOC) Explanation: Alteration in LOC is the earliest sign of deterioration in a patient with a hemorrhagic stroke; these include mild drowsiness, slight slurring of speech, and sluggish papillary reaction.
A client is following up after a visit to the emergency department where testing indicated that the client had suffered a transient ischemic attack. What lifestyle changes would the nurse include in teaching to prevent further reoccurrence? Select all that apply. - High-dose aspirin - Smoking cessation - Weight loss - Blood pressure control - Physical activity limitations
Correct response: Blood pressure control Weight loss Smoking cessation Explanation: Primary prevention of ischemic stroke remains the best approach. A healthy lifestyle including not smoking, engaging in physical activity (at least 40 minutes a day, 3 to 4 days a week), maintaining a healthy weight, and following a healthy diet (including modest alcohol consumption) can reduce the risk of having a stroke. Specific diets that have decreased risk of stroke include the Dietary Approaches to Stop Hypertension (DASH) diet (high in fruits and vegetables, moderate in low-fat dairy products, and low in animal protein), the Mediterranean diet (supplemented with nuts), and overall diets that are rich in fruits and vegetables. Research findings suggest that low-dose aspirin may lower the risk of a first stroke for those who are at risk.
A patient who just suffered a hemorrhagic stroke is brought to the emergency department by ambulance. What should be the nurse's primary assessment focus? - Cardiac and respiratory status - Urinary output - Seizure activity - Fluid and electrolyte balance
Correct response: Cardiac and respiratory status Explanation: Acute care begins with managing the ABC's. Patients may have difficulty keeping an open and clear airway secondary to decreased level of consciousness. Neurological assessment with close monitoring for signs of increased neurological deficit and seizure activity occurs next. Fluid and electrolyte balance must be controlled carefully, with the goal of adequate hydration to promote perfusion and decrease further brain damage.
A patient has been brought to the emergency department (ED) with signs and symptoms that are characteristic of an ischemic stroke. The ED nurse is aware that a disruption in cerebral blood flow will have initiated the ischemic cascade. The mitochondria in the patient's affected neurons respond to impaired blood supply by: - Changing from aerobic respiration to anaerobic metabolism - Metabolizing stored glucose contained in the cytoplasm - Releasing cytokines that signal the brain to shunt blood flow to alternative routes - Signaling the cell nucleus to synthesize oxygen
Correct response: Changing from aerobic respiration to anaerobic metabolism Explanation: The ischemic cascade begins when cerebral blood flow decreases to less than 25 mL/100 g/min. At this point, neurons are no longer able to maintain aerobic respiration. The cell's mitochondria must then switch to anaerobic metabolism, generating large amounts of lactic acid and causing a change in pH.
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 - Sudden numbness - Confusion - Epistaxis (nosebleed)
Correct response: Confusion Sudden numbness Visual disturbances Explanation: 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.
An emergency department (ED) nurse has administered an ordered bolus of tissue plasminogen activator (tPA) to a male patient who was diagnosed with stroke. During the administration of tPA, the nurse should prioritize assessments related to what problem? - Peripheral edema - Fluid overload - Hemorrhage - Acute pain
Correct response: Hemorrhage Explanation: 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). Edema, fluid overload, and pain are not likely to result from tPA.
The nurse is caring for a client diagnosed with a subarachnoid hemorrhage resulting from a leaking aneurysm. The client is awaiting surgery. Which nursing interventions would be appropriate for the nurse to implement? Select all that apply. - Elevate the head of bed 30 degrees. - Provide a dimly lit environment. - Ambulate the client every hour. - Administer docusate per order. - Permit friends to visit often.
Correct response: Provide a dimly lit environment. Elevate the head of bed 30 degrees. Administer docusate per order. Explanation: Cerebral aneurysm precautions are implemented for the patient with a diagnosis of aneurysm to provide a nonstimulating environment, prevent increases in intracranial pressure (ICP), and prevent further bleeding. The patient is placed on immediate and absolute bed rest in a quiet, nonstressful environment, because activity, pain, and anxiety elevate blood pressure, which increases the risk for bleeding. Visitors, except for family, are restricted. Dim lighting is helpful because photophobia (visual intolerance of light) is common. The head of the bed is elevated 15 to 30 degrees to promote venous drainage and decrease ICP. No enemas are permitted, but stool softeners (Colace) and mild laxatives are prescribed. Both prevent constipation, which would cause an increase in ICP, as would enemas.
A nurse is caring for a client with a cerebral aneurysm. Which nursing interventions would be most useful to the nurse to avoid bleeding in the brain? Select all that apply. - Report changes in neurologic status as soon as a worsening trend is identified. - Follow the healthcare provider's orders to increase fluid volume. - Maintain the head of the bed at 30 degrees. - Use a well-lighted room for assessments every 2 hours. - Avoid any activities that cause a Valsalva maneuver.
Correct response: Report changes in neurologic status as soon as a worsening trend is identified. Maintain the head of the bed at 30 degrees. Avoid any activities that cause a Valsalva maneuver. Explanation: Cerebral aneurysm precautions are implemented for the patient with a diagnosis of aneurysm to provide a nonstimulating environment, prevent increases in intracranial pressure, and prevent further bleeding. The patient is placed on bed rest in a quiet, nonstressful environment, because activity, pain, and anxiety are thought to elevate the blood pressure, which may increase the risk for bleeding. The head of the bed is elevated 30 degrees to promote venous drainage and decrease intracranial pressure. Any activity that suddenly increases the blood pressure or obstructs venous return is avoided. This includes the Valsalva maneuver, straining, forceful sneezing, pushing oneself up in bed and acute flexion or rotation of the head and neck (which compromises the jugular veins). Stool softeners and mild laxatives are prescribed to prevent constipation, which can cause an increase in intracranial pressure. Dim lighting is helpful for photophobia. Increasing fluid volume does not affect brain bleeding.
A patient diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for what purpose? - To prevent a stroke by removing atherosclerotic plaques blocking cerebral flow - To determine the cause of the TIA - To prevent seizure activity that is common following a TIA - To decrease cerebral edema
Correct response: To prevent a stroke by removing atherosclerotic plaques blocking cerebral flow Explanation: The main surgical procedure for select patients with TIAs is carotid endarterectomy, the removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in patients with occlusive disease of the extra cranial arteries. An endarterectomy does not decrease cerebral edema, prevent seizure activity, or determine the cause of a TIA.
The nurse plays a critical role in the initial work-up of a patient with acute stroke symptoms. An immediate decision is to determine if the stroke is ischemic or hemorrhagic. Although there is overlap in some motor, sensory, and cognitive changes, hemorrhagic strokes can be identified by some specific signs. Which of the following signs are consistent with a hemorrhagic stroke? Select all that apply. - Loss of balance - Sudden, severe headache - Vomiting - Numbness or weakness of an extremity - Seizures
Correct response: Vomiting Sudden, severe headache Seizures Explanation: These three signs are usually diagnostic of a hemorrhagic stroke. The other signs can occur with both hemorrhagic and ischemic stroke.
The nurse is performing stroke risk screenings at a hospital open house. Identification of high-risk individuals is the goal of the screenings. The nurse has identified four patients who might be at risk for a stroke. Which patient is likely at highest risk for a stroke? - White man, age 60 with history of uncontrolled hypertension - Black man, age 60, with history of diabetes - Black man, age 50 with history of smoking - White woman, age 60 with history of excessive alcohol intake
Correct response: White man, age 60 with history of uncontrolled hypertension Explanation: Uncontrolled hypertension is the primary cause of a hemorrhagic stroke. Control of hypertension, especially in individuals over 55 years of age, clearly reduces the risk for hemorrhagic stroke. Additional risk factors are increased age, male gender, and excessive alcohol intake. Another high-risk group is African Americans, where the incidence of first stroke is almost twice that in Caucasians. Modifiable risk factors for ischemic stroke include hypertension, atrial fibrillation, hyperlipidemia, obesity, smoking, and diabetes.
21) ** J - A nurse is reading a journal article about stroke and the underlying causes associated with this condition. The nurse demonstrates understanding of the information when identifying which subtype of stroke as being due to atrial fibrillation? large-artery thrombotic small, penetrating artery thrombotic cardio embolic cryptogenic
Correct response: cardio embolic Explanation: Ischemic strokes are further divided into five subtypes, according to a mechanism-based classification system: large-artery thrombotic strokes (representing 20% of ischemic strokes); small, penetrating artery thrombotic strokes (25%); cardio embolic strokes (20%); cryptogenic strokes (strokes that cannot be attributed to any specific cause) (30%); and "other" (5%). Large-artery thrombotic strokes are caused by atherosclerotic plaques in the large blood vessels of the brain. Thrombus formation and occlusion can occur at the site of the atherosclerosis and result in ischemia and infarction (tissue death). Small, penetrating artery thrombotic strokes that affect one or more vessels and cause reduced blood flow are the most common type of ischemic stroke, typically caused by longstanding hypertension, hyperlipidemia, or diabetes. Cardio embolic strokes are associated with cardiac dysrhythmias, such as atrial fibrillation, but can also be associated with valvular heart disease or left ventricular thrombus. The last two classifications of ischemic strokes are cryptogenic strokes, which have no identified cause, and strokes from other causes, such as illicit drug use (cocaine), coagulopathies, migraine, or spontaneous dissection of the carotid or vertebral arteries.
A 71-year-old man has made an appointment with his primary care provider at the urging of his wife, who states that he has occasionally had episodes of weakness and slurring of words over the past several weeks. The care provider recognizes the possibility that the man has been experiencing transient ischemic attacks (TIAs). TIAs have which of the following characteristics? -TIAs result in motor symptoms rather than sensory symptoms. -TIAs are a result of minor cerebral hemorrhages that spontaneously resolve. -TIAs cause irreversible, but minor, neurological damage -TIAs cause symptoms that last less than 1 hour.
TIAs cause symptoms that last less than 1 hour. Feedback: A TIA is defined as a brief episode of neurologic dysfunction caused by focal brain or retinal ischemia, with clinical symptoms typically lasting less than 1 hour, and without evidence of acute infarction. They may cause sensory symptoms and are not a result of hemorrhage.
