Chapter 57 - Stroke
A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which response by the nurse is accurate?
"The obstructing plaque is surgically removed from an artery in the neck." In a carotid endarterectomy, the carotid artery is incised and the plaque is removed.
A 63-year-old patient who began experiencing right arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol?
1. Administer oxygen to keep O2 saturation >95%. 2. Use National Institute of Health Stroke Scale to assess patient 3. Obtained CT scan without contrast 4. Infuse tissue plasminogen activator (tPA) The initial actions should be those that help with airway, breathing, and circulation. Baseline neurologic assessments should be done next. A CT scan will be needed to rule out hemorrhagic stroke before tPA can be administered.
A 40-year-old patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan?
Apply intermittent pneumatic compression stockings The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thromboembolism (VTE).
Several weeks after a stroke, a 50-year-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention will be best to include in the initial plan for an effective bladder training program?
Assist the patient onto the bedside commode every 2 hours Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full bladder.
The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to impaired self-feeding ability for a left-handed patient with left-sided hemiplegia. Which intervention should be included in the plan of care?
Assist the patient to eat with the right hand Because the nursing diagnosis indicates that the patient's imbalanced nutrition is related to the left-sided hemiplegia, the appropriate interventions will focus on teaching the patient to use the right hand for self-feeding.
A 70-year-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first?
Check the respiratory rate and effort The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway.
A 73-year-old patient with a stroke experiences facial drooping on the right side and right-sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find?
Difficulty comprehending instructions Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with comprehension and use of language. The left-side reflexes are likely to be intact. Impulsive behavior and neglect are more likely with a right-side stroke.
A male patient who has right-sided weakness after a stroke is making progress in learning to use the left hand for feeding and other activities. The nurse observes that when the patient's wife is visiting, she feeds and dresses him. Which nursing diagnosis is most appropriate for the patient?
Disabled family coping related to inadequate understanding by patient's spouse The information supports the diagnosis of disabled family coping because the wife does not understand the rehabilitation program.
A 72-year-old patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the patient says, "I don't need the aspirin today. I don't have a fever." Which action should the nurse take?
Explain that the aspirin is ordered to decrease stroke risk Aspirin is ordered to prevent stroke in patients who have experienced TIAs.
A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first?
Noncontrast computed tomography (CT) scan Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 4.5 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the less brain injury.
When caring for a patient with a new right-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care?
Place objects needed on the patient's left side During the acute period, the nurse should place objects on the patient's unaffected side.
Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness (LOC). Which nursing diagnosis do they determine has thehighest priority for the patient?
Risk for aspiration related to inability to protect airway Protection of the airway is the priority of nursing care for a patient having an acute stroke.
The home health nurse is caring for an 81-year-old who had a stroke 2 months ago. Based on information shown in the accompanying figure from the history, physical assessment, and physical therapy/occupational therapy, which nursing diagnosis is the highest priority for this patient?
Risk for caregiver role strain The spouse's household and patient care responsibilities, in combination with chronic illnesses, indicate a high risk for caregiver role strain. The nurse should further assess the situation and take appropriate actions.
A female patient who had a stroke 24 hours ago has expressive aphasia. The nurse identifies the nursing diagnosis of impaired verbal communication. An appropriate nursing intervention to help the patient communicate is to
ask questions that the patient can answer with "yes" or "no." Communication will be facilitated and less frustrating to the patient when questions that require a "yes" or "no" response are used.
A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours. The nurse will anticipate teaching the patient about
aspirin (Ecotrin) Following a transient ischemic attack (TIA), patients typically are started on medications such as aspirin to inhibit platelet function and decrease stroke risk.
A 47-year-old patient will attempt oral feedings for the first time since having a stroke. The nurse should assess the gag reflex and then
assist the patient into a chair The patient should be as upright as possible before attempting feeding to make swallowing easier and decrease aspiration risk.
A 58-year-old patient with a left-brain stroke suddenly bursts into tears when family members visit. The nurse should
explain to the family that depression is normal following a stroke Patients who have left-sided brain stroke are prone to emotional outbursts that are not necessarily related to the emotional state of the patient.
After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual effects, the nurse anticipates teaching the patient about
oral low-dose aspirin therapy The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent stroke.
For a patient who had a right hemisphere stroke the nurse establishes a nursing diagnosis of
risk for injury related to denial of deficits and impulsiveness The patient with right-sided brain damage typically denies any deficits and has poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair.
A 56-year-old patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously, and health records show a history of several transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for
tissue plasminogen activator (tPA) infusion The patient's history and clinical manifestations suggest an acute ischemic stroke and a patient who is seen within 4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan).
When teaching about clopidogrel (Plavix), the nurse will tell the patient with cerebral atherosclerosis
to call the health care provider if stools are bloody or tarry Clopidogrel (Plavix) inhibits platelet function and increases the risk for gastrointestinal bleeding, so patients should be advised to notify the health care provider about any signs of bleeding.
During the change of shift report a nurse is told that a patient has an occluded left posterior cerebral artery. The nurse will anticipate that the patient may have
visual deficits Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with middle cerebral artery involvement. Cognitive deficits and changes in judgment are more typical of anterior cerebral artery occlusion.
After receiving change-of-shift report on the following four patients, which patient should the nurse see first?
A 60-year-old patient with right-sided weakness who has an infusion of tPA prescribed tPA needs to be infused within the first few hours after stroke symptoms start in order to be effective in minimizing brain injury.
A patient admitted with possible stroke has been aphasic for 3 hours and his current blood pressure (BP) is 174/94 mm Hg. Which order by the health care provider should the nurse question?
Administer a labetalol (Normodyne) drip to keep BP less than 140/90 mm Hg Because elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if mean arterial pressure (MAP) is >130 mm Hg or systolic pressure is >220 mm Hg. Fluid intake should be 1500 to 2000 mL daily to maintain cerebral blood flow. The head of the bed should be elevated to at least 30 degrees, unless the patient has symptoms of poor tissue perfusion. tPA may be administered if the patient meets the other criteria for tPA use.
The nurse is caring for a patient who has been experiencing stroke symptoms for 60 minutes. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)?
Administer the prescribed short-acting insulin Administration of subcutaneous medications is included in LPN/LVN education and scope of practice.
A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider?
The patient has atrial fibrillation and takes warfarin (Coumadin) The use of warfarin probably contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding.
The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse?
The patient has difficulty speaking Small emboli can occur during carotid artery angioplasty and stenting, and the aphasia indicates a possible stroke during the procedure.
A 68-year-old patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin?
The patient reports that symptoms began with a severe headache A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated.
Which information about the patient who has had a subarachnoid hemorrhage is most important to communicate to the health care provider?
The patient's blood pressure (BP) is 90/50 mm Hg To prevent cerebral vasospasm and maintain cerebral perfusion, blood pressure needs to be maintained at a level higher than 90 mm Hg systolic after a subarachnoid hemorrhage. A low BP or drop in BP indicates a need to administer fluids and/or vasopressors to increase the BP.
Which stroke risk factor for a 48-year-old male patient in the clinic is most important for the nurse to address?
The patient's usual blood pressure (BP) is 170/94 mm Hg Hypertension is the single most important modifiable risk factor. People who drink more than 1 (for women) or 2 (for men) alcoholic beverages a day may increase risk for hypertension. Physical inactivity and obesity contribute to stroke risk but not as much as hypertension.