Chapter 62 MS2

A patient is admitted via ambulance to the emergency room of a stroke center at 1:30 p.m. with symptoms that the patient said began at 1:00 p.m. Within 1 hour, an ischemic stroke had been confirmed and the doctor ordered tPA. The nurse knows to give this drug no later than what time?

4:00 p.m.

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?

5.4mg

A nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform?

Call the physician immediately.

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

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

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention?

Keeping the client in one position to decrease bleeding

A client has experienced an ischemic stroke that has damaged the lower motor neurons of the brain. Which of the following deficits would the nurse expect during assessment?

Lack of deep tendon reflexes

Which of the following antiseizure medication has been found to be effective for post-stroke pain?

Lamotrigine (Lamictal)

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.

Maintain the head of the bed at 30 degrees. Report changes in neurologic status as soon as a worsening trend is identified. Avoid any activities that cause a Valsalva maneuver.

The nurse is caring for a client diagnosed with a hemorrhagic stroke. The nurse recognizes that which intervention is most important?

Maintaining a patent airway

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?

Migraines often coincide with menstrual cycle.

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?

Remove throw rugs and electrical cords from home environment.

A community health nurse is giving an educational presentation about stroke and heart disease at the local senior citizens' center. What nonmodifiable risk factor for stroke should the nurse cite?

Advanced age

A nurse is teaching a community group about modifiable and nonmodifiable risk factors for ischemic strokes. Which of the following is a risk factor that cannot be modified?

Advanced age

Which of the following is the most common side effect of tissue plasminogen activator (tPA)?

Bleeding

An emergency department nurse is interviewing a client who is presenting with signs of an ischemic stroke that began 2 hours ago. The client reports a history of a cholecystectomy 6 weeks ago and is taking digoxin, warfarin, and labetalol. What factor poses a threat to the client for thrombolytic therapy?

International normalized ratio greater than 2

What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke?

Left visual field deficit

The nurse is caring for a client following an aneurysm coiling procedure. The nurse documents that the client is experiencing Korsakoff syndrome. Which set of symptoms characterizes Korsakoff syndrome?

Psychosis, disorientation, delirium, insomnia, and hallucinations

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are:

Severe headache and early change in level of consciousness

The nurse is participating in a health fair for stroke prevention. Which will the nurse say is a modifiable risk factor for ischemic stroke?

Smoking

Which of the following, if left untreated, can lead to an ischemic stroke?

atrial fib

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 bestalternative medication to give is

aspirin.

Which term refers to the failure to recognize familiar objects perceived by the senses?

Agnosia

A 76-year-old 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?

Carotid endarterectomy

Which of the following is the initial diagnostic in suspected stroke?

Noncontrast computed tomography (CT)

The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regimen, to maintain a healthy weight, and to adopt a reasonable exercise program. This advice is based on research data that shows the most important risk factor for stroke is:

hypertension

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

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."

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?

"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?

"Stop smoking as soon as possible."

Thrombolytic therapy should be initiated within what time frame of an ischemic stroke to achieve the best functional outcome?

3 hours

An emergency department nurse understands that a 110-lb (50-kg) recent stroke victim will receive at least the minimum dose of recombinant tissue plasminogen activator (t-PA). What minimum dose will the client receive?

45mg

A 154-pound woman has been prescribed tPA (0.9 mg/kg) for an ischemic stroke. The nurse knows to give how many mg initially?

6.3 mg

Which term refers to the inability to perform previously learned purposeful motor acts on a voluntary basis?

Apraxia

Which interventions would be recommended for a client with dysphagia? Select all that apply.

Assist the client with meals. Test the gag reflex before offering food or fluids. Allow ample time to eat.

A client has experienced an ischemic stroke that has damaged the temporal (lateral and superior portions) lobe. Which of the following deficits would the nurse expect during assessment of this client?

Auditory agnosia

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?

Avoid heavy lifting.

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

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

The nurse is caring for a client with aphasia. Which strategy will the nurse use to facilitate communication with the client?

Establishing eye contact

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

A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to perform which action?

Form words that are understandable or comprehend spoken words

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

The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regimen, to maintain a healthy weight, and to adopt a reasonable exercise program. This advice is based on research data that shows the most important risk factor for stroke is:

HTN

A client is experiencing dysphagia following a stroke. Which measure may be taken by the nurse to ensure that the client's diet allows for easy swallowing?

Help the client sit upright when eating and feed slowly.

A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question?

Heparin sodium

A diagnostic test has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include thickened liquids. Which of the following is the priority nursing diagnosis for this client?

Impaired Swallowing

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

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?

Left-sided cerebrovascular accident (CVA)

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?

Limited attention span and forgetfulness

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?

Lioresal (Baclofen)

Which clinical manifestation would be exhibited by a client following a hemorrhagic stroke of the right hemisphere?

Neglect of the left side

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?

Noncontrast computed tomogram

A client is suspected of having had a stroke. Which is the initial diagnostic test for a stroke?

Noncontrast computed tomography

A client on your unit is scheduled to have intracranial surgery in the morning. Which nursing intervention helps to avoid intraoperative complications, reduce cerebral edema, and prevent postoperative vomiting?

Restrict fluids before surgery.

The nurse practitioner is able to correlate a patient's neurologic deficits with the location in the brain affected by ischemia or hemorrhage. For a patient with a left hemispheric stroke, the nurse would expect to see:

Right-sided paralysis.

The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient?

Semi-Fowler's

Which is a modifiable risk factor for transient ischemic attacks and ischemic strokes?

Smoking

The nurse has just received report on a client in the ED being transferred to the acute stroke unit with a diagnosis of a right hemispheric stroke. Which findings does the nurse understand is indicative of a right hemispheric stroke?

Spatial-perceptual deficits

What nursing intervention is appropriate for a client with receptive aphasia?

Speak slowly and clearly.

During the recovery phase of a neurologic deficit, assessment tools may be used to help identify a client's level of functioning. Which tool is used to measure performance in activities of daily living (ADL)?

The Barthel Index

When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke?

The day the patient has the stroke

A patient diagnosed with an ischemic stroke should be treated within the first 3 hours of symptom onset with which of the following?

Tissue plasminogen activator (tPA)

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?

Transient ischemic attack

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 nurse is providing education to a community group about ischemic strokes. One group member asks if there are ways to reduce the risk for stroke. Which of the following is a risk factor that can not be modified?

advanced age

If warfarin is contraindicated as a treatment for stroke, which medication is the best option?

aspirin

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?

bruit

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

While caring for clients who have suffered neurologic deficits from causes such as cerebrovascular accident and closed head injury, an important nursing goal that motivates nurses to offer the best care possible is preventing:

complications.

A nurse is providing care to a client who has had a stroke. Which symptoms are consistent with left-sided stroke?

expressive aphasia, defects in the right visual fields, problems with abstract thinking

A physician has ordered home health and physical therapy for an older adult who will be discharged home following an acute stroke. The nurse's discharge teaching should include instructions about:

reporting specific signs and symptoms to the physician, discharge medications, and dietary concerns.

A client admitted to the emergency department is being evaluated for the possibility of a stroke. Which assessment finding would lead the nurse to suspect that the client is experiencing a hemorrhagic stroke?

severe exploding headache

An emergency department nurse is awaiting the arrival of a client with signs of an ischemic stroke that began 1 hour ago, as reported by emergency medical personnel. The treatment window for thrombolytic therapy is which of the following?

three hours