Chapter 60 - Stroke (Questions)
The nurse is caring for a client who has had a subarachnoid hemorrhage and is being cared for in the intensive care unit. Which of the following information about vasospasms should the nurse be aware of when planning care? a. The client's blood pressure is 100/50 mm Hg. b. Endothelin will subside the vasospasm c. The cerebro-spinal fluid (CSF) report shows red blood cells (RBCs). d. Peak time for occurrence is 7-10 days post bleed.
ANS: D Peak time for vasospasm to occur is 7-10 days after the initial bleed. In addition, release of endothelin (a potent vasoconstrictor) may play a major role in the induction of cerebral vasospasm after SAH rather than helping to relieve it. The BP is within normal limits. RBCs in the CSF are a typical clinical manifestation of a subarachnoid hemorrhage.
The nurse is caring for a client who has recently had a stroke. When reviewing the clients' laboratory report, which of the following results should the nurse report the health care provider? a. PaCO2 51 mm Hg b. pH 7.41 c. PaO2 96 mm Hg d. WBC 9.2 x 10^9/L
ANS: A All of the lab values are within normal range except for the PaCO2. A high PaCO2 is a potent vasodilator that increases cerebral blood flow.
The health care provider prescribes clopidogrel for a client with cerebral atherosclerosis. Which of the following information should the nurse include when teaching the client about the new medication? a. Monitor and record the blood pressure daily. b. Call the health care provider if stools are tarry. c. It will dissolve clots in the cerebral arteries. d. It will reduce cerebral artery plaque formation.
ANS: B Plavix inhibits platelet function as it increases the risk for bleeding, so clients should be advised to notify the health care provider about any signs of bleeding. The medication does not lower blood pressure, decrease plaque formation, or dissolve clots.
The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to insufficient dietary intake (secondary to impaired self-feeding ability) for a client with right-sided hemiplegia. Which of the following interventions should be included in the plan of care? a. Provide a wide variety of food choices. b. Provide oral care before and after meals. c. Assist the client to eat with the left hand. d. Teach the client the "chin-tuck" technique.
ANS: C Because the nursing diagnosis indicates that the client's imbalanced nutrition is related to the right-sided hemiplegia, the appropriate interventions will focus on teaching the client to use the left hand for self-feeding. The other interventions are appropriate for clients with other etiologies for the imbalanced nutrition.
The nurse is assessing a client with a possible stroke and finds that the client's aphasia started 3.5 hours previously and the blood pressure is 170/92 mm Hg. Which of these prescriptions by the health care provider should the nurse question? a. Infuse normal saline at 75 mL/hour. b. Keep head of bed elevated at least 30 degrees. c. Administer tissue plasminogen activator (tPA) per protocol. d. Titrate labetalol drip to keep BP less than 140/90 mm Hg.
ANS: D 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 1 500-2 000 mL daily to maintain cerebral blood flow. The head of the bed should be elevated to at least 30 degrees, unless the client has symptoms of poor tissue perfusion. tPA may be administered if the client meets the other criteria for tPA use.
The nurse obtains all of the following information about a client in the clinic. When developing a plan to decrease stroke risk, which of the following risk factors is most important for the nurse to address? a. The client has a daily glass of wine to relax. b. The client is 13 kg above the ideal weight. c. The client works at a desk and relaxes by watching television. d. The client's blood pressure is usually about 180/90 mm Hg.
ANS: D Hypertension is the single most important modifiable risk factor and this client's hypertension is at the stage 2 level. 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 so much as hypertension.
The nurse is caring for a client with a stroke who has progressive development of neurological deficits with increasing weakness and decreased level of consciousness (LOC). Which of the following nursing diagnoses has the highest priority for the client? a. Impaired physical mobility related to decrease in muscle strength b. Risk for injury as evidenced by alteration in cognitive function c. Risk for impaired skin integrity as evidenced by pressure over bony prominence (immobilty) d. Risk for aspiration as evidenced by impaired ability to swallow
ANS: D Protection of the airway is the priority of nursing care for a client having an acute stroke. The other diagnoses also are appropriate, but interventions to prevent aspiration are the priority at this time.
A client with a history of several transient ischemic attacks (TIAs) arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. Which of the following procedures should the nurse anticipate? a. Surgical endarterectomy b. Transluminal angioplasty c. Intravenous heparin administration d. Tissue plasminogen activator (tPA) infusion
ANS: D The client's history and clinical manifestations suggest an acute ischemic stroke and a client who is seen within 3-4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy is not indicated for the client who is having an acute ischemic stroke.
The nurse is caring for a client with sudden-onset right-sided weakness who has a CT scan and is diagnosed with an intracerebral hemorrhage. Which of the following information about the client is most important to communicate to the health care provider? a. The client's speech is difficult to understand. b. The client's blood pressure is 144/90 mm Hg. c. The client takes a diuretic because of a history of hypertension. d. The client has atrial fibrillation and takes warfarin.
ANS: D The use of warfarin will have 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 client is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the client but has no immediate effect on the client's care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated.
The nurse is caring for a client who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects. Which of the following actions should the nurse anticipate as treatment for this client? a. Prophylactic clipping of cerebral aneurysms b. Heparin via continuous intravenous infusion c. Oral administration of low dose Aspirin therapy d. Therapy with tissue plasminogen activator (tPA)
ANS: C The client's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The client's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA.
The health care provider recommends a carotid endarterectomy for a client with carotid atherosclerosis and a history of transient ischemic attacks (TIAs). The client asks the nurse to describe the procedure. Which of the following responses by the nurse is appropriate? a. "The carotid endarterectomy involves surgical removal of plaque from an artery in the neck." b. "The diseased portion of the artery in the brain is removed and replaced with a synthetic graft." c. "A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed." d. "A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque."
ANS: A In a carotid endarterectomy, the carotid artery is incised and the plaque is removed. The response beginning, "The diseased portion of the artery in the brain is removed" describes an arterial graft procedure. The answer beginning, "A catheter with a deflated balloon is positioned at the narrow area" describes an angioplasty. The final response beginning, "A wire is threaded through the artery" describes the MERCI procedure.
The nurse is caring for a client who had a stroke resulting from a ruptured aneurysm and subarachnoid hemorrhage. Which of the following interventions should be included in the care plan? a. Applying compression gradient stockings b. Assisting to dangle on edge of bed and assess for dizziness c. Encouraging client to cough and deep breathe every 4 hours d. Inserting an oropharyngeal airway to prevent airway obstruction
ANS: A The client with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thrombo-embolism (VTE). Activities such as coughing and sitting up that might increase intracranial pressure (ICP)or decrease cerebral blood flow are avoided. Because there is no indication that the clientis unconscious, an oropharyngeal airway is inappropriate.
The nurse is admitting a client with left-sided hemiparesis who has arrived by ambulance to the emergency department. Which of the following actions should the nurse take first? a. Check the respiratory rate. b. Monitor the blood pressure. c. Send the client for a CT scan. d. Obtain the Glasgow Coma Scale score.
ANS: A The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway. The other activities should take place quickly after the CABs (circulation, airway, breathing) are completed.
The nurse is receiving a change-of-shift report. Which of the following clients should the nurse see first? a. A client with right-sided weakness who has an infusion of tPA prescribed b. A client who has atrial fibrillation and a new prescription for warfarin c. A client who experienced a transient ischemic attack yesterday who has a dose of Aspirin due. d. A client with a subarachnoid hemorrhage 2 days ago who has nimodipine scheduled
ANS: A tPA needs to be infused within the first few hours after stroke symptoms start in order to be effective in minimizing brain injury. The other medications also should be given as quickly as possible, but timing of the medications is not as critical.
The nurse identifies the nursing diagnosis of impaired verbal communication for a client with expressive aphasia. Which of the following actions should the nurse implement to help the client communicate? a. Have the client practice facial and tongue exercises. b. Ask simple questions that the client can answer with "yes" or "no." c. Develop a list of words that the client can read and practice reciting. d. Prevent embarrassing the client by changing the subject if the client does not respond.
ANS: B Communication will be facilitated and less frustrating to the client when questions that require a "yes" or "no" response are used. When the language areas of the brain are injured, the client might not be able to read or recite words, which will frustrate the client without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the client to respond.
Several weeks after a stroke, a client has urinary incontinence resulting from an impaired awareness of bladder fullness. For an effective bladder training program, which of the following nursing interventions will be best to include in the plan of care? a. Limit fluid intake to 1 200 mL daily to reduce urine volume. b. Assist the client onto the bedside commode every 2 hours. 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 client awareness of a full bladder. A 1 200 mL fluid restriction may lead to dehydration. Intermittent catheterization and use of a condom catheter are appropriate in the acute phase of stroke but should not be considered solutions for long-term management because of the risks for urinary tract infection (UTI) and skin breakdown.
The nurse is caring for a client who had a stroke and is in the acute phase of care. Which of the following systems is priority? a. Neurological system b. Respiratory system c. Gastro-intestinal system d. Genito-urinary system
ANS: B During the acute phase following a stroke, management of the respiratory system is a nursing priority. Stroke patients are particularly vulnerable to respiratory problems as it has been shown that respiratory muscle strength decreases following stroke. Advancing age and immobility increase the risk for atelectasis and pneumonia.
The nurse is teaching a client's family about immediate stroke care. Which of the following information should the nurse include in teaching plan? a. Hypotension post stroke is normal. b. Antihypertensive medication is administered if the mean arterial pressure is >130mm Hg. c. Diuretic ordered in the systolic BP is >160 mm Hg. d. Withholding medications until the degree of dysphasia is known.
ANS: B Elevated BP is common immediately after a stroke and may be a protective response to maintain cerebral perfusion. Immediately following ischemic stroke, use of drugs to lower BP is recommended only if BP is markedly increased (mean arterial pressure >130 mm Hg or systolic BP >220 mm Hg). Withholding medications can be dangerous; medications do not have to be given by the oral route.
A client is admitted to the hospital with dysphasia and right-sided weakness that resolves in a few hours. The nurse will anticipate teaching the client about a. Alteplase (tPA). b. Aspirin. c. Warfarin. d. Nimodipine.
ANS: B Following a TIA, clients typically are started on medications such as Aspirin to inhibit platelet function and decrease stroke risk. tPA is used for acute ischemic stroke. Warfarin is usually used for clients with atrial fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage.
The nurse is caring for a client who had a stroke affecting the right hemisphere of the brain. Which of the following nursing diagnoses is appropriate based on knowledge of the effects of right brain damage? a. Impaired physical mobility related to decrease in muscle control (right hemiplegia). b. Risk for injury as evidenced by alteration in cognitive functioning c. Impaired verbal communication related to environmental barrier (impaired speech) d. Ineffective coping related to insufficient sense of control (depression and distress about disability).
ANS: B Right-sided brain damage typically causes denial of any deficits and poor impulse control, leading to risk for injury when the client attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability.
A client who has a history of a transient ischemic attack (TIA) has an order for Aspirin 160 mg daily. When the nurse is administering the medications, the client says, "I don't need the Aspirin today. I don't have any aches or pains." Which of the following actions should the nurse take? a. Document that the Aspirin was refused by the client. b. Tell the client that the Aspirin is used to prevent aches. 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 clients who have experienced TIAs. Documentation of the client's refusal to take the medication is an inadequate response by the nurse. There is no need to clarify the order with the health care provider. The Aspirin is not ordered to prevent aches and pains.
The nurse is admitting a client with left-sided homonymous hemianopsia resulting from a stroke. Which of the following interventions should the nurse include in the plan of care during the acute period of the stroke? a. Apply an eye patch to the left eye. b. Approach the client from the left side. c. Place objects needed for activities of daily living on the client's right side. d. Reassure the client that the visual deficit will resolve as the stroke progresses.
ANS: C During the acute period, the nurse should place objects on the client's unaffected side. Since there is a visual defect in the left half of each eye, an eye patch is not appropriate. The client should be approached from the right side. The visual deficit may not resolve, although the client can learn to compensate for the defect.
The nurse is caring for a client who has had a stroke and has a new prescription to attempt oral feedings. After assessing the client's gag reflex, which of the following actions should the nurse do next? a. Order a varied puréed diet. b. Assess the client's appetite. c. Assist the client into a chair. d. Offer the client a sip of juice.
ANS: C The client should be as upright as possible before attempting feeding to make swallowing easier and decrease aspiration risk. To assess swallowing ability, the nurse should initially offer water or ice to the client. Puréed diets are not recommended because the texture is too smooth. The client may have a poor appetite, but the oral feeding should be attempted regardless.
The nurse is caring for a client who has right-sided weakness after a stroke and is attempting to use the left hand for feeding and other activities. The client's partner insists on feeding and dressing him, telling the nurse, "I just don't like to see him struggle." Which of the following nursing diagnoses is most appropriate for the client? a. Situational low self-esteem related to pattern of helplessness b. Interrupted family processes related to shift in family roles (effects of illness of a family member) c. Disabled family coping related to differing coping styles between support person and client d. Impaired nutrition: less than body requirements related to insufficient dietary intake (hemiplegia and aphasia)
ANS: C The information supports the diagnosis of disabled family coping because the client's partner does not understand the rehabilitation program. There are no data supporting low self-esteem, and the client is attempting independence. The data do not support an interruption in family processes because this may be a typical pattern for the couple. There is no indication that the client has impaired nutrition.
The nurse receives a verbal report that a client has an occlusion of the left posterior cerebral artery. Which of the following findings 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. Aphasia occurs with middle cerebral artery involvement. Cognitive deficits and changes in judgement are more typical of anterior cerebral artery occlusion.
The nurse is caring for a client with a left-sided brain stroke who suddenly bursts into tears when family members visit. Which of the following actions should the nurse implement? a. Use a calm voice to ask the client to stop the crying behaviour. b. Explain to the family that depression is normal following a stroke. c. Have the family members leave the client alone for a few minutes. d. Teach the family that emotional outbursts are common after strokes.
ANS: D Clients who have left-sided brain stroke are prone to emotional outbursts, which are not necessarily related to the emotional state of the client. Depression after a stroke is common, but the suddenness of the client's outburst suggests that depression is not the major cause of the behaviour. The family should stay with the client. The crying is not within the client's control and asking the client to stop will lead to embarrassment.
The nurse is admitting a client with right-sided weakness that started 90 minutes earlier to the emergency department and all these diagnostic tests are prescribed. Which of the following tests should be done first? a. Electrocardiogram (ECG) b. Complete blood count (CBC) c. Chest radiograph (chest x-ray) d. Noncontrast computed tomography (CT) scan
ANS: D 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 smaller the area of brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.
The nurse is admitting a client who had a stroke and is experiencing right-sided arm and leg paralysis and facial drooping on the right side. Which of the following clinical manifestations should the nurse expect to find? a. Impulsive behaviour b. Right-sided neglect c. Hyperactive left-sided reflexes d. Difficulty in understanding commands
ANS: D 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 behaviour and neglect are more likely with a right-side stroke.