Chapter 62: Management of Patients with Cerebrovascular Disorder
During a class on stroke, a junior nursing student asks what the clinical manifestations of stroke are. What would be the instructor's best answer?
"Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation. "Clinical manifestations following a stroke are highly variable and depend on the area of the cerebral cortex and the affected hemisphere, the degree of blockage (total, partial), and the presence or absence of adequate collateral circulation. (Collateral circulation is circulation formed by smaller blood vessels branching off from or near larger occluded vessels.)
A nurse is instructing the spouse of a client who suffered a stroke about the use of eating devices the client will be using. During the teaching, the spouse starts to cry and states, "One minute he is laughing, and the next he's crying; I just don't understand what's wrong with him." Which statement is the best response by the nurse? "You sound stressed; maybe using some stress management techniques will help." "This behavior is common in clients with stroke. Which does your spouse do more often? Laugh or cry?" "Emotional lability is common after a stroke, and it usually improves with time." "You seem upset, and it may be hard for you to focus on the teaching, I'll come back later."
"Emotional lability is common after a stroke, and it usually improves with time."
A family member brings the client 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 nurse's best answer? "Get medication to bring down your sodium levels." "Eat a nutritious diet." "Have your heart checked regularly." "Stop smoking as soon as possible."
"Stop smoking as soon as possible." Explanation: 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.
Thrombolytic therapy should be initiated within what time frame of an ischemic stroke to achieve the best functional outcome? 3 hours 6 hours 9 hours 12 hours
3 hours Explanation: Rapid diagnosis of stroke and initiation of thrombolytic therapy (within 3 hours) in clients with ischemic stroke lead to a decrease in the size of the stroke and an overall improvement in functional outcome after 3 months.
A patient had a carotid endarterectomy yesterday and when the nurse arrived in the room to perform an assessment, the patient states, "All of a sudden, I am having trouble moving my right side." What concern should the nurse have about this complaint? Bleeding from the endarterectomy site A thrombus formation at the site of the endarterectomy This is a normal occurrence after an endarterectomy and would not be a concern. Surgical wound infection
A thrombus formation at the site of the endarterectomy Explanation: Formation of a thrombus at the site of the endarterectomy is suspected if there is a sudden new onset of neurologic deficits, such as weakness on one side of the body.
failure to recognize familiar objects perceived by the senses.
Agnosia
Which term refers to the failure to recognize familiar objects perceived by the senses? Apraxia Agraphia Agnosia Perseveration
Agnosia Explanation: Auditory agnosia is failure to recognize significance of sounds. Agraphia refers to disturbances in writing intelligible words. Apraxia refers to an inability to perform previously learned purposeful motor acts on a voluntary basis. Perseveration is the continued and automatic repetition of an activity, word, or phrase that is no longer appropriate
Which term refers to the inability to perform previously learned purposeful motor acts on a voluntary basis? Agnosia Agraphia Perseveration Apraxia
Apraxia Explanation: Verbal apraxia refers to difficulty forming and organizing intelligible words although the musculature is intact. Agnosia is a failure to recognize familiar objects perceived by the senses. Agraphia refers to disturbances in writing intelligible words. Perseveration is the continued and automatic repetition of an activity or word or phrase that is no longer appropriate
Which term refers to the inability to perform previously learned purposeful motor acts on a voluntary basis?
Apraxia Explanation: Verbal apraxia refers to difficulty forming and organizing intelligible words although the musculature is intact. Agnosia is a failure to recognize familiar objects perceived by the senses. Agraphia refers to disturbances in writing intelligible words. Perseveration is the continued and automatic repetition of an activity or word or phrase that is no longer appropriate. Reference:
Which of the following, if left untreated, can lead to an ischemic stroke? Atrial fibrillation Arteriovenous malformation (AVM) Ruptured cerebral arteries Cerebral aneurysm
Atrial fibrillation Explanation: Atrial fibrillation is the most frequently diagnosed arrhythmia in the United States. If left untreated, it can lead to an ischemic stroke. Cerebral hemorrhage, arteriovenous malformation, and cerebral hemorrhage can lead to a hemorrhagic stroke. Cerebral aneurysm, arteriovenous malformations, and ruptured cerebral arteries can lead to hemorrhagic stroke.
A client has just been diagnosed with an aneurysm. In planning discharge teaching for this client, what instructions should be delivered by the nurse to the client?a) Take opioid analgesics b) Avoid heavy lifting. c) Take an herbal form of feverfew. d) Include peanut butter, bread, or tart foods in the diet.
Avoid heavy lifting. A client with an aneurysm should be advised to avoid heavy lifting, extreme emotional situations, or straining of stools because they may increase intracranial pressure and thereby headaches
Which of the following is the most common side effect of tissue plasminogen activator (tPA)? Headache Increased intracranial pressure (ICP) Bleeding Hypertension
Bleeding 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). Headache, increased ICP, and hypertension are not side effects of tPA.
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. Physical activity limitations Smoking cessation High-dose aspirin Blood pressure control Weight loss
Blood pressure control Weight loss Smoking cessation
The provider diagnoses the patient as having had an ischemic stroke. The etiology of an ischemic stroke would include which of the following? Cardiogenic emboli Arteriovenous malformation Cerebral aneurysm Intracerebral hemorrhage
Cardiogenic emboli Explanation: Aneurysms, hemorrhages, and malformations are all examples of a hemorrhagic stroke. An embolism can block blood flow, leading to ischemia.
A patient presents to the emergency room with complaints of having an "exploding headache" for the last 2 hours. The patient is immediately seen by a triage nurse who suspects the patient is experiencing a stroke. Which of the following is a possible cause based on the characteristic symptom? Cerebral aneurysm Large artery thrombosis Small artery thrombosis Cardiogenic emboli
Cerebral aneurysm Explanation: A cerebral aneurysm is a type of hemorrhagic stroke that is characterized by an exploding headache.
After the patient has received tPA, the nurse knows to check vital signs every 30 minutes for 6 hours. Which of the following readings would require calling the provider?
Diastolic pressure of 110 mm Hg Explanation: A diastolic pressure reading of over 105 mm Hg warrants notifying the health care provider. The other choices are within normal range.
The nurse is caring for a client with a history of transient ischemic attacks (TIAs) and moderate carotid stenosis who has undergone a carotid endarterectomy. Which postoperative finding would cause the nurse the most concern? Difficulty swallowing Mild neck edema Neck pain rated 3 of 10 (on a 0 to 10 pain scale) Blood pressure 128/86 mm Hg
Difficulty swallowing Explanation: The client's inability to swallow without difficulty would cause the nurse the most concern.
After a stroke, a client is admitted to the facility. The client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g. Which nursing intervention is a priority for this client? Elevating the head of the bed to 30 degrees Checking stools for occult blood Keeping skin clean and dry Performing range-of-motion (ROM) exercises on the left side
Elevating the head of the bed to 30 degrees Explanation: Because the client's gag reflex is absent, elevating the head of the bed to 30 degrees helps minimize the client's risk of aspiration. Checking the stools, performing ROM exercises, and keeping the skin clean and dry are important, but preventing aspiration through positioning is the priority.
The nurse is caring for a patient with aphasia. Which of the following strategies will the nurse use to facilitate communication with the patient? a) Speaking loudly b) Avoiding the use of hand gestures c) Establishing eye contact d) Speaking in complete sentences
Establishing eye contact The following strategies should be used by the nurse to encourage communication with a patient with aphasia: face the patient and establish eye contact, speak in your usual manner and tone, use short phrases, and pause between phrases to allow the patient time to understand what is being said; limit conversation to practical and concrete matters; use gestures, pictures, objects, and writing; and as the patient uses and handles an object, say what the object is. It helps to match the words with the object or action, be consistent in using the same words and gestures each time you give instructions or ask a question, and keep extraneous noises and sounds to a minimum. Too much background noise can distract the patient or make it difficult to sort out the message being spoken.
How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tPA)? Every 45 minutes Every hour Every 30 minutes Every 15 minutes
Every 15 minutes Explanation: Neurological assessment and vital signs (except temperature) should be taken every 15 minutes initially while the patient is receiving tPA infusion.
A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to do perform which action?
Form understandable words and comprehend spoken words Explanation: Global aphasia is a combination of expressive and receptive aphasia and presents a tremendous challenge to the nurse to communicate effectively with the client. In receptive and expressive aphasia, the client is unable to form words that are understandable. The client who is unable to speak at all is referred to as mute.
From which direction should a nurse approach a client who is blind in the right eye? From the left side of the client From directly in front of the client From directly behind the client From the right side of the client
From the left side of the client Explanation: The nurse should approach the client from the left side so that the client can be aware of the nurse's approach. Likewise, personal items should be placed on the client's left side so that he can see them easily.
A stroke victim is experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe? Frontal Temporal Parietal Occipital
Frontal Explanation: If damage has occurred to the frontal lobe, learning capacity, memory, or other higher cortical intellectual functions may be impaired. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and a lack of motivation.
A client undergoes cerebral angiography for evaluation of a subarachnoid hemorrhage. Which findings indicate spasm or occlusion of a cerebral vessel by a clot? Difficulty breathing or swallowing Tachycardia, tachypnea, and hypotension Hemiplegia, seizures, and decreased level of consciousness Nausea, vomiting, and profuse sweating
Hemiplegia, seizures, and decreased level of consciousness Explanation: Spasm or occlusion of a cerebral vessel by a clot causes signs and symptoms similar to those of a stroke: hemiplegia, seizures, decreased level of consciousness, aphasia, hemiparesis, and increased focal symptoms. Nausea, vomiting, and profuse sweating suggest a delayed reaction to the contrast medium used in cerebral angiography. Difficulty breathing or swallowing may signal a hematoma in the neck. Tachycardia, tachypnea, and hypotension suggest internal hemorrhage.
A client undergoes cerebral angiography for evaluation of a subarachnoid hemorrhage. Which findings indicate spasm or occlusion of a cerebral vessel by a clot? Difficulty breathing or swallowing Nausea, vomiting, and profuse sweating Hemiplegia, seizures, and decreased level of consciousness Tachycardia, tachypnea, and hypotensio
Hemiplegia, seizures, and decreased level of consciousness Explanation: Spasm or occlusion of a cerebral vessel by a clot causes signs and symptoms similar to those of a stroke: hemiplegia, seizures, decreased level of consciousness, aphasia, hemiparesis, and increased focal symptoms. Nausea, vomiting, and profuse sweating suggest a delayed reaction to the contrast medium used in cerebral angiography. Difficulty breathing or swallowing may signal a hematoma in the neck. Tachycardia, tachypnea, and hypotension suggest internal hemorrhage. Reference:
A client undergoes cerebral angiography for evaluation after an intracranial computed tomography scan revealed a subarachnoid hemorrhage. Afterward, the nurse checks frequently for signs and symptoms of complications associated with this procedure. Which findings indicate spasm or occlusion of a cerebral vessel by a clot? a) Tachycardia, tachypnea, and hypotension b) Nausea, vomiting, and profuse sweating c) Hemiplegia, seizures, and decreased level of consciousness (LOC) d) Difficulty breathing or swallowing
Hemiplegia, seizures, and decreased level of consciousness (LOC) Spasm or occlusion of a cerebral vessel by a clot causes signs and symptoms similar to those of a stroke: hemiplegia, seizures, decreased LOC, aphasia, hemiparesis, and increased focal symptoms.
A physician orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? a) Dexamethasone (Decadron) b) Heparin sodium c) Phenytoin (Dilantin) d) Methyldopa (Aldomet)
Heparin sodium Administering heparin, an anticoagulant, could increase the bleeding associated with hemorrhagic stroke. Therefore, the nurse should question this order to prevent additional hemorrhage in the brain
A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? Dexamethasone Phenytoin Heparin sodium Methyldopa
Heparin sodium Explanation: Administering heparin, an anticoagulant, could increase the bleeding associated with hemorrhagic stroke. Therefore, the nurse should question this order to prevent additional hemorrhage in the brain. In a client with hemorrhagic stroke, the healthcare provider may use dexamethasone (Decadron) to decrease cerebral edema and pressure, methyldopa (Aldomet) to reduce blood pressure, and phenytoin (Dilantin) to prevent seizures.
Which term will the nurse use when referring to blindness in the right or left half of the visual field in both eyes? Diplopia Nystagmus Scotoma Homonymous hemianopsia
Homonymous hemianopsia Explanation: Homonymous hemianopsia occurs with occipital lobe tumors. Scotoma refers to a defect in vision in a specific area in one or both eyes. Diplopia refers to double vision or the awareness of two images of the same object occurring in one or both eyes. Nystagmus refers to rhythmic, involuntary movements or oscillations of the eyes.
A client is receiving an IV infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To confirm that this drug is producing its therapeutic effect, the nurse should consider which finding most significant?
Increased urine output Explanation: The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output. A decreased LOC and elevated blood pressure may indicate lack of therapeutic effectiveness. A decreased heart rate doesn't indicate that mannitol is effective.
A nurse is caring for an older client who has had a hemorrhagic stroke. The client has exhibited impulsive behavior and, despite reminders from the nurse, doesn't recognize his limitations. Which priority measure should the nurse implement to prevent injury? a) Install a bed alarm to remind the client to ask for assistance and to alert staff that the client is getting out of bed. b) Encourage the client to do as much as possible without assistance, and to use the call light only in emergencies. c) Encourage the family to reprimand the client if he doesn't ask for help with transfers and mobility. d) Ask a physician to order a vest and wrist restraints.
Install a bed alarm to remind the client to ask for assistance and to alert staff that the client is getting out of bed. The bed alarm will alert staff that the client is attempting to transfer, so they can come to assisy
Which is a contraindication for the administration of tissue plasminogen activator (t-PA)? Ischemic stroke Systolic blood pressure less than or equal to 185 mm Hg Age 18 years or older Intracranial hemorrhage
Intracranial hemorrhage Explanation: Intracranial hemorrhage, neoplasm, and aneurysm are contraindications for t-PA. Clinical diagnosis of ischemic stroke, age 18 years or older, and a systolic blood pressure less than or equal to 185 mm Hg are eligibility criteria.
A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings? a) Left-sided cerebrovascular accident (CVA) b) Right-sided cerebrovascular accident (CVA) c) Completed Stroke d) Transient ischemic attack (TIA)
Left-sided cerebrovascular accident (CVA) When the infarct is on the left side of the brain, the symptoms are likely to be on the right, and the speech is more likely to be involved. If the MRI reveals an infarct, TIA is no longer the diagnosis.
A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings? Completed Stroke Left-sided cerebrovascular accident (CVA) Transient ischemic attack (TIA) Right-sided cerebrovascular accident (CVA)
Left-sided cerebrovascular accident (CVA) Explanation: When the infarct is on the left side of the brain, the symptoms are likely to be on the right, and the speech is more likely to be involved. If the MRI reveals an infarct, TIA is no longer the diagnosis. There is not enough information to determine if the stroke is still evolving or is complete.
A client has experienced an ischemic stroke that has damaged the frontal lobe of his brain. Which of the following deficits does the nurse expect to observe during assessment? a) Hemiplegia or hemiparesis b) Limited attention span and forgetfulness c) Visual and auditory agnosia d) Lack of deep tendon reflexes
Limited attention span and forgetfulness Damage to the frontal lobe may impair learning capacity, memory, or other higher cortical intellectual functions. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and a lack of motivation
A client has experienced an ischemic stroke that has damaged the frontal lobe of his brain. Which of the following deficits does the nurse expect to observe during assessment? Lack of deep tendon reflexes Visual and auditory agnosia Hemiplegia or hemiparesis Limited attention span and forgetfulness
Limited attention span and forgetfulness Explanation: Damage to the frontal lobe may impair learning capacity, memory, or other higher cortical intellectual functions. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and a lack of motivation. Damage to the motor neurons may cause hemiparesis, hemiplegia, and a change in reflexes. Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia.
A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem? Pregabalin (Lyrica) Lioresal (Baclofen) Diphenhydramine (Benadryl) Heparin
Lioresal (Baclofen) Explanation: Spasticity, particularly in the hand, can be a disabling complication after stroke. Botulinum toxin type A injected intramuscularly into wrist and finger muscles has been shown to be effective in reducing this spasticity (although the effect is temporary, typically lasting 2 to 4 months) (Teasell, Foley, Pereira, et al., 2012). Other treatments for spasticity may include stretching, splinting, and oral medications such as baclofen (Lioresal).
Which of the following is accurate regarding a hemorrhagic stroke? a) It is caused by a large-artery thrombosis. b) One of the main presenting symptoms is numbness or weakness of the face. c) Main presenting symptom is an "exploding headache." d) Functional recovery usually plateaus at 6 months.
Main presenting symptom is an "exploding headache. "One of hemorrhagic stroke's main presenting symptom is an "exploding headache." In ischemic stroke, functional recovery usually plateaus at 6 months; it may be caused by a large artery thrombosis and may have a presenting symptoms of numbness or weakness of the face.
The nurse is caring for a patient diagnosed with a hemorrhagic stroke. The nurse recognizes that which of the following interventions is most important? a) Maintaining a patent airway b) Elevating the head of the bed at 30 degrees c) Administering a stool softener d) Monitoring for seizure activity
Maintaining a patent airway Maintaining the airway is the most important nursing intervention. Immediate complications of a hemorrhagic stroke include cerebral hypoxia, decreased cerebral blood flow, and extension of the area of injury. Providing adequate oxygenation of blood to the brain minimizes cerebral hypoxia. Brain function depends on delivery of oxygen to the tissues. Administering supplemental oxygen and maintaining the hemoglobin and hematocrit at acceptable levels will assist in maintaining tissue oxygenation.
A female client who reports recurring headaches, accompanied by increased irritability, photophobia, and fatigue is asked to track the headache symptoms and occurrence on a calendar log. Which is the best nursing rationale for this action? Tension headaches are easier to treat. Cluster headaches can cause severe debilitating pain. Migraines often coincide with menstrual cycle. Headaches are the most common type of reported pain.
Migraines often coincide with menstrual cycle. Explanation: Changes in reproductive hormones as found during menstrual cycle can be a trigger for migraine headaches and may assist in the management of the symptoms. Cluster headaches can cause severe pain but are not the reason for tracking. Tension headaches can be managed but is not associated with a monthly calendar. Headaches are common but not the reason for tracking.
Which clinical manifestation would be exhibited by a client following a hemorrhagic stroke of the right hemisphere? Neglect of the left side Inability to move the right arm Expressive aphasia Neglect of the right side
Neglect of the left side Explanation: This client would have deficits on the left side. Expressive aphasia typically occurs with left-hemisphere stroke.
A transcranial Doppler ultrasonography detects cerebral vasospasms in a client experiencing lethargy 8 days following a subarachnoid hemorrhage. The nurse anticipates which therapeutic intervention? Phenytoin IV Nimodipine PO Nitroprusside IV Fluid restriction
Nimodipine PO Explanation: Medication may be effective in the treatment of vasospasm. Based on one theory, that vasospasm is caused by an increased influx of calcium into the cell, medication therapy may be used to block or antagonize this action and prevent or reverse the action of vasospasm if already present. The most frequently used calcium channel blocker is nimodipine. The other interventions and medications are not used to treat vasospasms.
A patient is brought to the emergency department with a possible stroke. What initial diagnostic test for a stroke, usually performed in the emergency department, would the nurse prepare the patient for? Carotid ultrasound study Transcranial Doppler flow study Noncontrast computed tomogram 12-lead electrocardiogram
Noncontrast computed tomogram Explanation: The initial diagnostic test for a stroke is usually a noncontrast computed tomography (CT) scan. This should be performed within 25 minutes or less from the time the patient presents to the emergency department (ED) to determine if the event is ischemic or hemorrhagic (the category of stroke determines treatment).
Which is the initial diagnostic test for a stroke? Electrocardiography Carotid Doppler Noncontrast computed tomography Transcranial Doppler studies
Noncontrast computed tomography Explanation: The initial diagnostic test for a stroke is nonconstrast computed tomography performed emergently to determine whether the event is ischemic or hemorrhagic. Further diagnostics include a carotid Doppler, electrocardiogram, and transcranial Doppler.
Which of the following is the initial diagnostic in suspected stroke? a) Cerebral angiography b) Magnetic resonance imaging (MRI) c) Noncontrast computed tomography (CT) d) CT with contrast
Noncontrast computed tomography (CT) An initial head CT scan will determine whether or not the patient is experiencing a hemorrhagic stroke. An ischemic infarction will not be readily visible on initial CT scan if it is performed within the first few hours after symptoms onset; however, evidence of bleeding will almost always be visible.
A nurse is planning care for a client who experienced a stroke in the right hemisphere of his brain. What should the nurse do? Provide close supervision because of the client's impulsiveness and poor judgment. Anticipate the client will exhibit some degree of expressive or receptive aphasia. Place the wheelchair on the client's left side when transferring him into a wheelchair. Support the right arm with a sling or pillow to prevent subluxation
Provide close supervision because of the client's impulsiveness and poor judgment. Explanation: The primary symptoms of a client who experiences a right-sided stroke are left-sided weakness, impulsiveness, and poor judgment. Aphasia is more commonly present when the dominant or left hemisphere is damaged. When a client has one-sided weakness, the nurse should place the wheelchair on the client's unaffected side. Because a right-sided stroke causes left-sided paralysis, the right side of the body should remain unaffected.
A client has tension headaches. The nurse recommends massage as a treatment for tension headaches. How does massage help clients with tension headaches? a) Relieves migraines b) Relaxes muscles c) Reduces hypotension d) Increases appetite
Relaxes muscles Massaging relaxes tense muscles, causes local dilation of blood vessels, and relieves headache. However, this approach is not likely to help a client with migraine or cluster headaches. Massage is not offered to clients with tension headaches to increase their appetite or reduce hypotens
The geriatric advanced practice nurse (APN) is doing client teaching with a client who has had a cerebrovascular accident (CVA) and the client's family. One concern the APN addresses is a potential for falls related to the CVA and resulting muscle weakness. What would be most important for the APN to include in teaching related to this concern? Use of tripod cane. Remove throw rugs and electrical cords from home environment. Need for support group due to decreased self image related to restricted mobility. Leg exercises to strengthen muscle weakness.
Remove throw rugs and electrical cords from home environment. Explanation: Client and family teaching is essential and focuses on the following points: Remove throw rugs, clutter, and electrical cords from the client's home environment to reduce the potential for falls. Although the other interventions may be appropriate, they are not as directly related to reducing fall risk.
The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient? a) Semi-Fowler's b) Supine c) High-Fowler's d) Prone
Semi-Fowler's The head of the bed is elevated 15 to 30 degrees (semi-Fowler's position) to promote venous drainage and decrease intracranial pressure
A patient is exhibiting classic signs of a hemorrhagic stroke. What complaint from the patient would be an indicator of this type of stroke? a) Dizziness and tinnitus b) Numbness of an arm or leg c) Severe headache d) Double vision
Severe headache The patient with a hemorrhagic stroke can present with a wide variety of neurologic deficits, similar to the patient with ischemic stroke. The conscious patient most commonly reports a severe headache.
While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are: Confusion or change in mental status Severe headache and early change in level of consciousness Weakness on one side of the body and difficulty with speech Foot drop and external hip rotation
Severe headache and early change in level of consciousness Explanation: The main presenting symptoms for ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body, confusion or change in mental status, and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Foot drop and external hip rotation can occur if a stroke victim is not turned or positioned correctl
The nurse is participating in a health fair for stroke prevention. Which will the nurse say is a modifiable risk factor for ischemic stroke? Advanced age Thyroid disease Social drinking Smoking
Smoking Explanation: Modifiable risk factors for transient ischemic attack (TIA) and ischemic stroke include hypertension, type 1 diabetes, cardiac disease, smoking, and chronic alcoholism. Advanced age, gender, and race are nonmodifiable risk factors for stroke.
A client who's paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis? The client leaves the side rails down. The client hangs the left arm over the side of the wheelchair. The client uses a mirror to inspect the skin. The client repositions only after being reminded to do so.
The client uses a mirror to inspect the skin. Explanation: The client demonstrates understanding of safety measures related to paralysis when he uses a mirror to inspect his skin. The mirror enables the client to inspect all areas of the skin for signs of breakdown without the help of staff or family members. The client should keep the side rails up to help with repositioning and to prevent falls.
A nurse is teaching a community class that those experiencing symptoms of ischemic stroke need to enter the medical system early. The primary reason for this is which of the following? Thrombolytic therapy has a time window of only 3 hours. A ruptured intracranial aneurysm must quickly be repaired. A ruptured arteriovenous malformation will cause deficits until it is stopped. Intracranial pressure is increased by a space-occupying bleed.
Thrombolytic therapy has a time window of only 3 hours. Explanation: Currently approved thrombolytic therapy for ischemic strokes has a treatment window of only 3 hours after the onset of symptoms. Urgency is needed on the part of the public for rapid entry into the medical system. The other three choices are related to hemorrhagic strokes.
A client is hospitalized when presenting to the emergency department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to his presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what? Cerebral aneurysm Right-sided stroke Left-sided stroke Transient ischemic attack
Transient ischemic attack Explanation: A transient ischemic attack (TIA) is a sudden, brief attack of neurologic impairment caused by a temporary interruption in cerebral blood flow. Symptoms may disappear within 1 hour; some continue for as long as 1 day. When the symptoms terminate, the client resumes his or her presymptomatic state. The symptoms do not describe a left- or right-sided stroke or a cerebral aneurysm.
Which of the following is the chief cause of intracerebral hemorrhage (ICH)? a) Diabetes b) Uncontrolled hypertension c) Migraine headaches d) Hypercholesterolemia
Uncontrolled hypertension Primary intracerebral hemorrhage (ICH) from a spontaneous rupture of small arteries or arterioles accounts for approximately 80% of hemorrhagic strokes and is caused chiefly by uncontrolled hypertension.
The nurse is providing information about strokes to a community group. Which of the following would the nurse identify as the primary initial symptoms of an ischemic stroke?
Weakness on one side of the body and difficulty with speech
A client diagnosed with a stroke is ordered to receive warfarin. Later, the nurse learns that the warfarin is contraindicated and the order is canceled. The nurse knows that the best alternative medication to give is
aspirin. Explanation: If warfarin is contraindicated, aspirin is the best option, although other medications may be used if both are contraindicated.
A client reports light-headedness, speech disturbance, and left-sided weakness that have lasted for several hours. In the examination, an abnormal sound is auscultated in an artery leading to the brain. What is the term for the auscultated discovery? TIA atherosclerotic plaque bruit diplopia
bruit Explanation: A neurologic examination during an attack reveals neurologic deficits. Auscultation of the artery may reveal a bruit (abnormal sound caused by blood flowing over a rough surface within one or both carotid arteries). The term for the auscultated discovery is "bruit."
A client reports light-headedness, speech disturbance, and left-sided weakness that have lasted for several hours. In the examination, an abnormal sound is auscultated in an artery leading to the brain. What is the term for the auscultated discovery? diplopia atherosclerotic plaque TIA bruit
bruit Explanation: A neurologic examination during an attack reveals neurologic deficits. Auscultation of the artery may reveal a bruit (abnormal sound caused by blood flowing over a rough surface within one or both carotid arteries). The term for the auscultated discovery is "bruit."
A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the health care provider in the emergency department. Which is the origin of the client's symptoms?
impaired cerebral circulation
A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the health care provider in the emergency department. Which is the origin of the client's symptoms? diabetes insipidus cardiac disease impaired cerebral circulation hypertension
impaired cerebral circulation Explanation: TIAs involve the same mechanism as in the ischemic cascade, but symptoms are transient (< 24 hours) and there is no evidence of cerebral tissue infarction. The ischemic cascade begins when cerebral blood flow decreases to less than 25 mL/100 g/min and neurons are no longer able to maintain aerobic respiration. Thus, a TIA results directly from impaired blood circulation in the brain. Atherosclerosis, cardiac disease, hypertension, or diabetes can be risk factors for a TIA but do not cause it.
A nurse in a rehabilitation facility is coordinating the discharge of a client who is tetraplegic. The client, who is married and has two children in high school, is being discharged to home and will require much assistance. Who would the discharge planner recognize as being the most important member of this client's care team? home care nurse spouse chaplain physical therapist
spouse Explanation: The client's spouse and family would need to be involved in the everyday care of the client; without their support, it is unlikely that the client would be able to manage at home.
A 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? cardio embolic cryptogenic large-artery thrombotic small, penetrating artery thrombotic
cardio embolic
