Chapter 57: Stroke
A female patient who had a stroke 24 hrs ago has expressive aphasia. What is an appropriate nursing intervention to help the patient communicate? a. ask questions that the patient can answer with 'yes' or 'no' b. develop a list of words that the patient can read and practice reciting c. have the patient practice her facial and tongue exercises with a mirror d. prevent embarrassing the patient by answering for her if she does not respond
ANS: A Communication will be facilitated and less frustrating to the patient when questions require a 'yes' or 'no' response are used.
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. Which patient problem do they determine has the highest priority for the patient? a. risk for aspiration b. impaired skin integrity c. impaired physical mobility d. disturbed sensory perception
ANS: A Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other diagnoses are also appropriate, but interventions to prevent aspiration are the priority at this time.
A patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will the nurse include in the plan of care? a. apply intermittent pneumatic compression stockings b. assist to dangle on edge of bed and assess for dizziness c. encourage patient to cough and deep breathe every four hours d. insert an oropharyngeal airway to prevent airway obstruction
ANS: A The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thromboembolism.
After receiving change-of-shift report on the following four patients, which patient should the nurse see first? a. 60-yr-old patient with right-sided weakness who has an infusion of tPA prescribed b. 50-yr-old patient who has atrial fibrillation and a new order for warfarin c. 30-yr-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine scheduled d. 40-yr-old patient who had a transient ischemic attack yesterday and has a dose of aspirin due
ANS: A tPA needs to be infused within the first few hours after stroke symptoms start to be effective in minimizing brain injury.
A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours. What topic should the nurse anticipate teaching the patient? a. tPA b. aspirin c. warfarin d. nimodipine
ANS: B After a transient ischemic attack, patients typically are started on medications such as aspirin to inhibit platelet function and decrease stroke risk.
What will the nurse tell the patient who has cerebral atherosclerosis about taking clopidogrel? a. monitor and record the BP daily b. call the health care provider if stools are tarry c. clopidogrel will dissolve clots in cerebral arteries d. clopidogrel will reduce cerebral artery plaque formation
ANS: B Clopidogrel inhibits platelet function and increases the risk for GI bleeding, so patients should be advised to notify the health care provider about any signs of bleeding.
Several weeks after a stroke, a 50yr old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention should be planned to begin an effective bladder training program? a. limit fluid intake to 1200mL daily to reduce urine volume b. assist the patient onto the bedside commode every 2hrs c. perform intermittent catheterization after each voiding to check for residual urine d. use an external 'condom' catheter to protect the skin and prevent embarrassment
ANS: B Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full bladder.
A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which response by the nurse is accurate? a. " The diseased portion of the artery is replaced with a synthetic graft." b. "The obstructing plaque is surgically removed from inside an artery in the neck." c. "A wire is threaded through an artery in the leg to the clots in the carotid artery, and clots are removed." d. "A catheter with a deflated balloon is positioned at the narrow area, and the balloon flattens the plaque."
ANS: B In a carotid endarterectomy, the carotid artery is incised, and the plaque is removed.
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? a. pulse rate is 102 b. patient has difficulty speaking c. blood pressure is 144/86 d. there are fine crackles at the lung bases
ANS: B Small emboli can occur during carotid artery angioplasty and stenting, and the aphasia indicates a possible stroke during the procedure.
A 70yr old female patient with left-sided hemiparesis arrives by ambulance to the ED. Which action should the nurse take first? a. take the patient's BP b. check the RR and effort c. assess the Glasgow Coma Scale score d. send the patient for a CT scan
ANS: B The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway.
Which information about the patient who had a subarachnoid hemorrhage is most important to communicate to the health care provider? a. patient reports having a stiff neck b. patient's blood pressure is 90/50 c. patient reports a severe and unrelenting headache d. cerebrospinal fluid report shows red blood cells
ANS: B To prevent cerebral vasospasm and maintain cerebral perfusion, BP needs to be maintained at a level higher than 90 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.
A patient is being admitted with a possible stoke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving a prescribed dose of aspirin? a. patient has dysphasia b. patient has atrial fibrillation c. patient reports that symptoms began with a severe headache d. patient has a history of brief episodes of right-sided hemiplegia
ANS: C A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated.
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? a. assess the patient's gag and cough reflexes b. determine when the stroke symptoms began c. administer the prescribed short-acting insulin d. infuse the prescribed IV metoprolol
ANS: C Administration of subcutaneous medications is included in LPN/VN education and scope of practice.
A 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? a. document that the patient refused the aspirin b. tell the patient that the aspirin is used to prevent a fever c. explain that the aspirin is ordered to decrease stroke risk d. call the health care provider to clarify the medication order
ANS: C Aspirin is ordered to prevent stroke in patients who have experienced TIAs.
A patient admitted with possible stroke has been aphasic for 3 hours and has a current BP of 174/94. Which order by the health care provider should the nurse question? a. keep head of bed elevated at least 30 degrees b. infuse normal saline intravenously at 75mL/hr c. start a labetalol drip to keep BP less than 140/90 d. begin tissue plasminogen activator (tPA) intravenously per protocol
ANS: C Because elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if the MAP is greater than 130 or systolic pressure is greater than 220.
A left-handed patient with left-sided hemiplegia has difficulty feeding himself. Which intervention should the nurse include in the plan of care? a. provide a wide variety of food choices b. provide oral care before and after meals c. assist the patient to eat with the right side d. teach the patient the 'chin-tuck' technique
ANS: C Because the patient has difficulty feeding himself, the appropriate interventions will focus on teaching the patient to use the right hand for self-feeding.
Which intervention should the nurse include in the plan of care for a patient with new right-sided homonymous hemianopsia after a stroke? a. apply an eye patch to the right eye b. approach the patient from the right side c. place needed objects on the patient's left side d. teach the patient that the left visual deficit will resolve
ANS: C During the acute period, the nurse should place objects on the patient's unaffected side.
Which stroke risk factor for a 48-yr-old male patient in the clinic is most important for the nurse to address? a. patient is 25 pounds above the ideal weight b. patient drinks a glass of red wine with dinner daily c. patient's usual blood pressure is 170/94 d. patient works at a desk and relaxes by watching television
ANS: C Hypertension is the single most important modifiable risk factor.
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? a. complete blood count b. chest x-ray c. computed tomography scan d. 12-Lead electrocardiogram
ANS: C Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator, 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.
A patient will attempt oral feedings for the first time after having a stroke. After assessing the gag reflex, what action should the nurse take? a. order a varied pureed diet b. assess the patient's appetite c. assist the patient into a chair d. offer the patient a sip of juice
ANS: C The patient should be as upright as possible before attempting to feed to make swallowing easier and decrease aspiration risk.
What concern should the nurse anticipate for a patient who had a right hemisphere stroke? a. right sided hemiplegia b. speech-language deficits c. denial of deficits and impulsiveness d. depression and distress about disability
ANS: C 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.
What topic should the nurse anticipate teaching a patient who had a brief episode of tinnitus, diplopia, and dysarthria with no residual effects? a. cerebral aneurysm clipping b. heparin intravenous infusion c. oral low dose aspirin therapy d. tissue plasminogen activator (tPA)
ANS: C The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent a stroke.
The home health nurse is caring for an 81-yr-old who had a stroke 2 months ago. Based on patient information shown, which action should the nurse take? Hx- Well controlled type II diabetes for 10yrs, married 45yrs and spouse has heart failure and COPD Physical Assessment- A/O to person, place, time; and minimal weakness of left leg Physical/Occupational Therapy- uses cane with walking, spouse does household cleaning, cleaning, and assists patient with bathing and dressing a. teach about preventing hypoglycemia b. begin processes to obtain a wheelchair c. provide support to the spouse caregiver d. remind the patient to take prescribed medications
ANS: C The spouse's household and patient care responsibilities, in combination with chronic illnesses, indicate a high risk for caregiver role strain. The nurse should take appropriate actions to provide support to the souse caregiver. The data about the control of the patient's diabetes indicates that hypoglycemia and medication adherence are not a current concern.
During change of shift report, a nurse is told a patient has an occluded left posterior cerebral artery. What finding should the nurse anticipate? a. dysphasia b. confusion c. visual deficits d. poor judgement
ANS: C Visual disturbances are expected with posterior cerebral artery occlusion.
A 63-yr-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? a. obtain CT scan without contrast b. infuse tissue plasminogen activator c. administer oxygen to keep O2 saturation >95% d. use National Institute of Health Stroke Scale to assess patient
ANS: C, D, A, B 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 patient with a left-brain stroke suddenly bursts into tears when family members visit. How should the nurse respond? a. use a calm voice to ask the patient to stop the crying behavior b. explain to the family that depression is normal following a stroke c. have the family members leave the patient alone for a few minutes d. teach the family that emotional outbursts are common after strokes
ANS: D Patients who have left-sided brain stroke are prone to emotional outbursts that are not necessarily related to the emotional state of the patient.
A patient being admitted with a stroke has right-sided facial drooping and right-sided arm and leg paralysis. Which finding should the nurse expect? a. impulsive behavior b. right-sided neglect c. hyperactive left-sided tendon reflexes d. difficulty comprehending instructions
ANS: D Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with comprehension and use of language.
A patient arrives in the ED with hemiparesis and dysarthria that started 2 hrs previously. Health records show a history of several transient ischemic attacks. What should the nurse anticipate for this patient? a. surgical endarterectomy b. transluminal angioplasty c. intravenous heparin drip administration d. tissue plasminogen activator infusion
ANS: D The patient's history and clinical manifestations suggest an acute ischemic stroke, and a patient who is seen within 4.5 hrs of stroke onset is likely to receive tPA.
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? a. patient's speech is difficult to understand b. patient's blood pressure is 144/90 c. patient takes a diuretic because of a history of hypertension d. patient has atrial fibrillation and takes warfarin
ANS: D 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.