chapter 67 STROKE- NCLEX

A patient is in the acute phase of an ischemic stroke. How long does the nurse know that this phase may last? a) Up to 1 week b) Up to 24 hours c) 1 to 3 days d) Up to 2 weeks

1 to 3 days The acute phase of an ischemic stroke may last 1 to 3 days, but ongoing monitoring of all body systems is essential as long as the patient requires care.

A nurse knows that, for a patient with an ischemic stroke, tPA is contraindicated if the blood pressure reading is: a) 170 mm Hg/105 mm Hg b) 185 mm Hg/110 mm Hg c) 190 mm Hg/120 mm Hg d) 175 mm Hg/100 mm Hg

190 mm Hg/120 mm Hg Elevated blood pressure (systolic >185; diastolic >110 mm Hg) is a contraindication to tPA.

TRUE

Administering heparin, an anticoagulant, could increase the bleeding associated with hemorrhagic stroke. Therefore, the nurse should question this order (HEPARIN ) to prevent additional hemorrhage in the brain.

Which of the following terms refer to the failure to recognize familiar objects perceived by the senses? a) Agnosia b) Perseveration c) Apraxia d) Agraphia

Agnosia Auditory agnosia is failure to recognize significance of sounds. Agraphia refers to disturbances in writing intelligible words. Apraxia refers to 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.

What is the drug classification of Clopidogrel and dipyridamole?

Antiplatelet- platelet inhibiting meds

Patients with a decreased field of vision should be approached on the side where the visual perception is intact or the opposite side of the defect?

Approach the patient from side of intact field of vision.

Which of the following terms refer to the inability to perform previously learned purposeful motor acts on a voluntary basis? a) Agraphia b) Perseveration c) Agnosia d) Apraxia

Apraxia Verbal apraxia refers to difficulty in forming and organizing intelligible words although the musculature is intact. Agnosia is 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. (less)

A patient diagnosed with a stroke is ordered to receive warfarin (Coumadin). 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 which of the following? a) Ticlodipine (Ticlid) b) Dipyridamole (Persantine) c) Clopidogrel (Plavix) d) Aspirin

Aspirin If warfarin is contraindicated, aspirin is the best option, although other medications may be used if both are contraindicated.

A preceptor is discussing stroke with a new nurse on the unit. The preceptor would tell the new nurse which cardiac dysrhythmia is associated with cardiogenic embolic strokes? A) Ventricular tachycardia B) Atrial fibrillation C) Supraventricular tachycardia D) Bundle branch block

B) Atrial fibrillation

TRUE

Brain function depends on delivery of oxygen to the tissues

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? A) Female gender B) Asian American race C) Advanced age D) Smoking

C) Advanced age

What is the cause of increased intracranial pressure (ICP)?

CEREBRAL EDEMA

TRUE

Careful maintenance of cerebral hemodynamics to maintain cerebral perfusion is extremely important after a stroke.

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? a) Cerebral aneurysm b) Cardiogenic emboli c) Large artery thrombosis d) Small artery thrombosis

Cerebral aneurysm A cerebral aneurysm is a type of hemorrhagic stroke that is characterized by an exploding headache.

Which of the following statements reflect nursing management of the patient with expressive aphasia? a) Frequently reorient the patient to time, place, and situation b) Speak clearly to the patient in simple sentences, use gestures or pictures when able c) Speak slowly and clearly to assist the patient in forming the sounds d) Encourage the patient to repeat sounds of the alphabet

Encourage the patient to repeat sounds of the alphabet Nursing management of the patient with expressive aphasia includes encouraging the patient to repeat sounds of the alphabet. Nursing management of the patient with global aphasia includes speaking clearly to the patient in simple sentences and using gestures or pictures when able. Nursing management of the patient with receptive aphasia includes speaking slowing and clearly to assist the patient in forming the sounds. Nursing management of the patient with cognitive deficits, such as memory loss, includes frequently reorienting the patient to time, place, and situation. (less)

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) Avoiding the use of hand gestures b) Establishing eye contact c) Speaking in complete sentences d) Speaking loudly

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. (less)

A patient has been diagnosed as having global aphasia. The nurse recognizes that the patient will be unable to do which of the following actions? a) Form words that are understandable b) Speak at all c) Form words that are understandable or comprehend the spoken word d) Comprehend the spoken word

Form words that are understandable or comprehend the spoken word Global aphasia is a combination of expressive and receptive aphasia and presents tremendous challenge to the nurse to effectively communicate with the patient. In receptive aphasia, the patient is unable to form words that are understandable. In expressive aphasia, the patient is unable to form words that are understandable. The patient who is unable to speak at all is referred to as mute.

A physician orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? a) Phenytoin (Dilantin) b) Methyldopa (Aldomet) c) Heparin sodium d) Dexamethasone (Decadron)

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. In a client with hemorrhagic stroke, the physician may use dexamethasone to decrease cerebral edema and pressure; methyldopa, to reduce blood pressure; and phenytoin, to prevent seizures.

Which disturbance results in loss of half of the visual field? a) Anisocoria b) Homonymous hemianopsia c) Nystagmus d) Diplopia

Homonymous hemianopsia Homonymous hemianopsia (loss of half of the visual field) may occur from stroke and may be temporary or permanent. Double vision is documented as diplopia. Nystagmus is ocular bobbing and may be seen in multiple sclerosis. Anisocoria is unequal pupils.

A client is receiving an I.V. infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant? a) Elevated blood pressure b) Decreased level of consciousness (LOC) c) Increased urine output d) Decreased heart rate

Increased urine output 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 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? a) Maintaining the client in a quiet environment b) Keeping the client in one position to decrease bleeding c) Positioning the client to prevent airway obstruction d) Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess

Keeping the client in one position to decrease bleeding The student nurse shouldn't keep the client in one position. She should carefully reposition the client often (at least every hour). The client needs to be positioned so that a patent airway can be maintained. Fluid administration must be closely monitored to prevent complications such as increased intracranial pressure. The client must be maintained in a quiet environment to decrease the risk of rebleeding.

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? a) Maintaining the client in a quiet environment b) Positioning the client to prevent airway obstruction c) Keeping the client in one position to decrease bleeding d) Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess

Keeping the client in one position to decrease bleeding The student nurse shouldn't keep the client in one position. She should carefully reposition the client often (at least every hour). The client needs to be positioned so that a patent airway can be maintained. Fluid administration must be closely monitored to prevent complications such as increased intracranial pressure. The client must be maintained in a quiet environment to decrease the risk of rebleeding.

What is the trade name for Atorvastatin?

LIPITOR

Which of the following antiseizure medication has been found to be effective for post-stroke pain? a) Carbamazepine (Tegretol) b) Lamotrigine (Lamictal) c) Topiramate (Topamax) d) Phenytoin (Dilantin)

Lamotrigine (Lamictal) The antiseizure medication lamotrigine (Lamictal) has been found to be effective for post-stroke pain.

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? a) Pregabalin (Lyrica) b) Diphenhydramine (Benadryl) c) Heparin d) Lioresal (Baclofen)

Lioresal (Baclofen) 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). (less)

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

What is the drug classification for Naproxen?

NSAID

Which of the following is the initial diagnostic test for a stroke? a) Noncontrast CT scan b) Transcranial Doppler studies c) ECG d) Carotid Doppler

Noncontrast CT scan The initial diagnostic test for a stroke is a nonconstrast CT scan performed emergently to determine if the event is ischemic or hemorrhagic. Further diagnostics include a carotid Doppler, ECG, and a transcranial Doppler. (less)

What is the trade name of Clopidogrel?

PLAVIX

The nurse is caring for a patient with dysphagia. Which of the following interventions would be contraindicated while caring for this patient? a) Allowing ample time to eat b) Assisting the patient with meals c) Testing the gag reflex prior to offering food or fluids d) Placing food on the affected side of mouth

Placing food on the affected side of mouth Interventions for dysphagia include placing food on the unaffected side of the mouth, allowing ample time to eat, assisting the patient with meals, and testing the patient's gag reflex prior to offering food or fluids.

What do platelets need to be above for Tissue Plasminogen Activator (tPA)?

Platelet count ≥100,000/mm

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are: a) Footdrop and external hip rotation b) Severe headache and early change in level of consciousness c) Confusion or change in mental status d) Weakness on one side of the body and difficulty with speech

Severe headache and early change in level of consciousness 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. Footdrop and external hip rotation can occur if a stroke victim is not turned or positioned correctly. (less)

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are: a) Footdrop and external hip rotation b) Severe headache and early change in level of consciousness c) Weakness on one side of the body and difficulty with speech d) Confusion or change in mental status

Severe headache and early change in level of consciousness 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. Footdrop and external hip rotation can occur if a stroke victim is not turned or positioned correctly. (less)

An emergency department nurse is interviewing a client with signs of an ischemic stroke that began 2 hours ago. The client reports that she had a cholecystectomy 6 weeks ago and is taking digoxin, coumadin, and labetelol. This client is not eligible for thrombolytic therapy for which of the following reasons? a) She is not within the treatment time window. b) She had surgery 6 weeks ago. c) She is taking digoxin. d) She is taking coumadin.

She is taking coumadin. To be eligible for thrombolytic therapy, the client cannot be taking coumadin. Initiation of thrombolytic therapy must be within 3 hours in clients with ischemic stroke. The client is not eligible for thrombolytic therapy if she has had surgery within 14 days. Digoxin and labetelol do not prohibit thrombolytic therapy.

16. A physician orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? a. Heparin sodium b. Dexamethasone (Decadron) c. Methyldopa (Aldomet) d. Phenytoin (Dilantin)

a. Heparin sodium

10. From which direction should a nurse approach a client who is blind in the right eye? a. From directly in front of the client b. From the right side of the client c. From the left side of the client d. From directly behind the client

c. From the left side of the client

13. A patient is exhibiting classic signs of a hemorrhagic stroke. What complaint from the patient would be an indicator of this type of stroke13% a. Numbness of an arm or leg b. Double vision c. Severe headache d. Dizziness and tinnitus

c. Severe headache

2. A client who has experienced an initial transient ischemic attack (TIA) states: "I'm glad it wasn't anything serious." Which is the best nursing response to this statement? a. "I sense that you are happy it was not a stroke". b. "People who experience a TIA will develop a stroke". c. "TIA symptoms are short-lived and resolve within 24 hours". d. "TIA is a warning sign. Let's talk about lowering your risks."

d. "TIA is a warning sign. Let's talk about lowering your risks."

What is the drug classification of Aspirin?

salicylate___

What is Dexamethasone (decadron) used for?

to decrease cerebral edema and pressure;

What is phenytoin (Dilantin) used for?

to prevent seizures.

What is methyldopa (Aldomet) used for?

to reduce blood pressure

When communicating with a client who has sensory (receptive) aphasia, the nurse should: a) speak loudly and articulate clearly. b) allow time for the client to respond. c) give the client a writing pad. d) use short, simple sentences.

use short, simple sentences. Although sensory aphasia allows the client to hear words, it impairs the ability to comprehend their meaning. The nurse should use short, simple sentences to promote comprehension. Allowing time for the client to respond might be helpful but is less important than simplifying the communication. Because the client's hearing isn't affected, speaking loudly isn't necessary. A writing pad is helpful for clients with expressive, not receptive, aphasia.

Name a common medication that patients will be prescribed if they have atrial fibrillation?

warfarin (Coumadin)

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? a) 5:30 p.m. b) 3:00 p.m. c) 4:00 p.m. d) 2:30 p.m.

4:00 p.m. Tissue plasminogen activator (tPA) must be given within 3 hours after symptom onset. Therefore, since symptom onset was 1:00 pm, the window of opportunity ends at 4:00 pm.

A client is admitted to the intensive care unit (ICU) with a diagnosis of cerebrovascular accident (CVA). Which assessment by the nurse provides the most significant finding in differentiating between ischemic and hemorrhagic strokes? a) Oropharyngeal suctioning as needed. b) Kepprais ordered for treatment of focal seizures. c) A unit of fresh frozen plasma is infusing. d) Neurological checks are ordered every 2 hours.

A unit of fresh frozen plasma is infusing. FFP is usedin the treatment of clotting deficiencies as seen with over dose of anticoagulants and would indicate a hemorrhagic stroke. Neuro checks ordered every 2 hours does not differentiate between types of strokes. Focal seizures can occur with any stroke and would not differentiate. Suctioning is a nursing action taken to maintain airway and does not indicate a specific type of stroke.

A patient who just suffered a suspected ischemic stroke is brought to the ED by ambulance. On what should the nurse's primary assessment focus? A) Cardiac and respiratory status B) Seizure activity C) Pain D) Fluid and electrolyte balance

A) Cardiac and respiratory status

A patient is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this patient is aware that an absolute contraindication for thrombolytic therapy is what? A) Evidence of hemorrhagic stroke B) Blood pressure of 180/110 mm Hg C) Evidence of stroke evolution D) Previous thrombolytic therapy within the past 12 months

A) Evidence of hemorrhagic stroke

The nurse is assessing a patient with a suspected stroke. What assessment finding is most suggestive of a stroke? A) Facial droop B) Dysrhythmias C) Periorbital edema D) Projectile vomiting

A) Facial droop

When preparing to discharge a patient home, the nurse has met with the family and warned them that the patient may exhibit unexpected emotional responses. The nurse should teach the family that these responses are typically a result of what cause? A) Frustration around changes in function and communication B) Unmet physiologic needs C) Changes in brain activity during sleep and wakefulness D) Temporary changes in metabolism

A) Frustration around changes in function and communication

During a patient's recovery from stroke, the nurse should be aware of predictors of stroke outcome in order to help patients and families set realistic goals. What are the predictors of stroke outcome? Select all that apply. A) National Institutes of Health Stroke Scale (NIHSS) score B) Race C) LOC at time of admission D) Gender E) Age

A) National Institutes of Health Stroke Scale (NIHSS) score C) LOC at time of admission E) Age

After a major ischemic stroke, a possible complication is cerebral edema. Nursing care during the immediate recovery period from an ischemic stroke should include which of the following? A) Positioning to avoid hypoxia B) Maximizing PaCO2 C) Administering hypertonic IV solution D) Initiating early mobilization

A) Positioning to avoid hypoxia

A patient who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurse's care of this patient? A) The patient should be approached on the side where visual perception is intact. B) Attention to the affected side should be minimized in order to decrease anxiety. C) The patient should avoid turning in the direction of the defective visual field to minimize shoulder subluxation. D) The patient should be approached on the opposite side of where the visual perception is intact to promote recovery.

A) The patient should be approached on the side where visual perception is intact.

A nurse is caring for a client who has returned to his room after a carotid endarterectomy. Which action should the nurse take first? a) Take the client's blood pressure. b) Ask the client if he has a headache. c) Ask the client if he has trouble breathing. d) Place antiembolism stockings on the client.

Ask the client if he has trouble breathing. The nurse should first assess the client's breathing. A complication of a carotid endarterectomy is an incisional hematoma, which could compress the trachea causing breathing difficulty for the client. Although the other measures are important actions, they aren't the nurse's top priority.

A family member brings the patient 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? A) "Have your heart checked regularly." B) "Stop smoking as soon as possible." C) "Get medication to bring down your sodium levels." D) "Eat a nutritious diet."

B) "Stop smoking as soon as possible."

When caring for a patient who has had a stroke, a priority is reduction of ICP. What patient position is most consistent with this goal? A) Head turned slightly to the right side B) Elevation of the head of the bed C) Position changes every 15 minutes while awake D) Extension of the neck

B) Elevation of the head of the bed

A patient has recently begun mobilizing during the recovery from an ischemic stroke. To protect the patient's safety during mobilization, the nurse should perform what action? A) Support the patient's full body weight with a waist belt during ambulation. B) Have a colleague follow the patient closely with a wheelchair. C) Avoid mobilizing the patient in the early morning or late evening. D) Ensure that the patient's family members do not participate in mobilization.

B) Have a colleague follow the patient closely with a wheelchair.

As a member of the stroke team, the nurse knows that thrombolytic therapy carries the potential for benefit and for harm. The nurse should be cognizant of what contraindications for thrombolytic therapy? Select all that apply. A) INR above 1.0 B) Recent intracranial pathology C) Sudden symptom onset D) Current anticoagulation therapy E) Symptom onset greater than 3 hours prior to admission

B) Recent intracranial pathology D) Current anticoagulation therapy E) Symptom onset greater than 3 hours prior to admission

A 73-year-old client is visiting the neurologist. The 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? a) Atherosclerotic plaque b) TIA c) Diplopia d) Bruit

Bruit 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.

The pathophysiology of an ischemic stroke involves the ischemic cascade, which includes the following steps: 1. Change in pH 2. Blood flow decreases 3. A switch to anaerobic respiration 4. Membrane pumps fail 5. Cells cease to function 6. Lactic acid is generated Put these steps in order in which they occur. A) 635241 B) 352416 C) 236145 D) 162534

C) 236145

The nurse is reviewing the medication administration record of a female patient who possesses numerous risk factors for stroke. Which of the woman's medications carries the greatest potential for reducing her risk of stroke? A) Naproxen 250 PO b.i.d. B) Calcium carbonate 1,000 mg PO b.i.d. C) Aspirin 81 mg PO o.d. D) Lorazepam 1 mg SL b.i.d. PRN

C) Aspirin 81 mg PO o.d.

A patient diagnosed with a hemorrhagic stroke has been admitted to the neurologic ICU. The nurse knows that teaching for the patient and family needs to begin as soon as the patient is settled on the unit and will continue until the patient is discharged. What will family education need to include? A) How to differentiate between hemorrhagic and ischemic stroke B) Risk factors for ischemic stroke C) How to correctly modify the home environment D) Techniques for adjusting the patient's medication dosages at home

C) How to correctly modify the home environment

1. A patient has had an ischemic stroke and has been admitted to the medical unit. What action should the nurse perform to best prevent joint deformities? A) Place the patient in the prone position for 30 minutes/day. B) Assist the patient in acutely flexing the thigh to promote movement. C) Place a pillow in the axilla when there is limited external rotation. D) Place patient's hand in pronation.

C) Place a pillow in the axilla when there is limited external rotation.

A patient diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for what purpose? A) To decrease cerebral edema B) To prevent seizure activity that is common following a TIA C) To remove atherosclerotic plaques blocking cerebral flow D) To determine the cause of the TIA

C) To remove atherosclerotic plaques blocking cerebral flow

The public health nurse is planning a health promotion campaign that reflects current epidemiologic trends. The nurse should know that hemorrhagic stroke currently accounts for what percentage of total strokes in the United States? A) 43% B) 33% C) 23% D) 13%

D) 13%

A patient diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse? A) Sit with the patient for a few minutes. B) Administer an analgesic. C) Inform the nurse-manager. D) Call the physician immediately.

D) Call the physician immediately.

A nursing student is writing a care plan for a newly admitted patient who has been diagnosed with a stroke. What major nursing diagnosis should most likely be included in the patient's plan of care? A) Adult failure to thrive B) Post-trauma syndrome C) Hyperthermia D) Disturbed sensory perception

D) Disturbed sensory perception

A female patient is diagnosed with a right-sided stroke. The patient is now experiencing hemianopsia. How might the nurse help the patient manage her potential sensory and perceptional difficulties? A) Keep the lighting in the patient's room low. B) Place the patient's clock on the affected side. C) Approach the patient on the side where vision is impaired. D) Place the patient's extremities where she can see them.

D) Place the patient's extremities where she can see them.

After a subarachnoid hemorrhage, the patient's laboratory results indicate a serum sodium level of less than 126 mEq/L. What is the nurse's most appropriate action? A) Administer a bolus of normal saline as ordered. B) Prepare the patient for thrombolytic therapy as ordered. C) Facilitate testing for hypothalamic dysfunction. D) Prepare to administer 3% NaCl by IV as ordered.

D) Prepare to administer 3% NaCl by IV as ordered.

The nurse is caring for a patient with a history of transient ischemic attacks (TIAs) and moderate carotid stenosis who has undergone a carotid endarterectomy. Which of the following postoperative findings would cause the nurse the most concern? a) Blood pressure (BP): 128/86 mm Hg b) Neck pain: 3/10 (0 to 10 pain scale) c) Mild neck edema d) Difficulty swallowing

Difficulty swallowing The patient's inability to swallow without difficulty would cause the nurse the most concern. Difficulty in swallowing, hoarseness or other signs of cranial nerve dysfunction must be assessed. The nurse focuses on assessment of the following cranial nerves: facial (VII), vagus (X), spinal accessory (XI), and hypoglossal (XII). Some edema in the neck after surgery is expected; however, extensive edema and hematoma formation can obstruct the airway. Emergency airway supplies, including those needed for a tracheostomy, must be available. The patient's neck pain and mild BP elevation need addressing but would not cause the nurse the most concern. Hypotension is avoided to prevent cerebral ischemia and thrombosis. Uncontrolled hypertension may precipitate cerebral hemorrhage, edema, hemorrhage at the surgical incision, or disruption of the arterial reconstruction.

What will alteration in level of consciousness (LOC) look like for this patient? Name two symptoms.

Drowsiness, slight slurring of speech, sluggish pupillary reaction

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) Completed Stroke c) Transient ischemic attack (TIA) d) Right-sided cerebrovascular accident (CVA)

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. There is not enough information to determine if the stroke is still evolving or is complete.

A client with a cerebrovascular accident (CVA) is having difficulty with eating food on the plate. Which is the best nursing action to be taken? a) Reposition the tray and plate. b) Perform a vision field assessment. c) Know this is a normal finding for CVA. d) Assist the client with feeding.

Perform a vision field assessment. The nurse should perform a vision field assessment to evaluate the client forhemianopia. This finding could indicate damage to the visual area of the brain as a result of evolving CVA. Repositioning the tray and assisting with feeding would not be the best nursing action until new finding has been evaluated. Hemianopia can be associated with a CVA but, when presenting as a new finding, should be evaluated and reported immediately. (less)

8. A nurse in the ICU is providing care for a patient who has been admitted with a hemorrhagic stroke. The nurse is performing frequent neurologic assessments and observes that the patient is becoming progressively more drowsy over the course of the day. What is the nurse's best response to this assessment finding? a. Report this finding to the physician as an indication of decreased metabolism. b. Provide more stimulation to the patient and monitor the patient closely. c. Recognize this as the expected clinical course of a hemorrhagic stroke. d. Report this to the physician as a possible sign of clinical deterioration.

Report this to the physician as a possible sign of clinical deterioration.

14. 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? a. 6.3 mg b. 7.5 mg c. 8.3 mg d. 10 mg

a. 6.3 mg - bolus 56.7mg- infusion dose

6. A nurse is assisting with a community screening for people at high risk for stroke. To which of the following clients would the nurse pay most attention? a. A 60-year-old African-American man b. A 40-year-old Caucasian woman c. A 62-year-old Caucasian woman d. A 28-year-old pregnant African-American woman

a. A 60-year-old African-American man

11. Which of the following is a contraindication for the administration of tissue plasminogen activator (t-PA)? a. Intracranial hemorrhage b. Ischemic stroke c. Age 18 years of age or older d. Systolic blood pressure less than or equal to 185 mm Hg

a. Intracranial hemorrhage

15. What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke? a. Left visual field deficit b. Aphasia c. Slow, cautious behavior d. Altered intellectual ability

a. Left visual field deficit

3. When caring for a patient who had a hemorrhagic stroke, close monitoring of vital signs and neurologic changes is imperative. What is the earliest sign of deterioration in a patient with a hemorrhagic stroke of which the nurse should be aware? a. Generalized pain b. Alteration in level of consciousness (LOC) c. Tonic-clonic seizures d. Shortness of breath

b. Alteration in level of consciousness (LOC)

12. A client with a history of atrial fibrillation has experienced a TIA. In an effort to reduce the risk of cerebrovascular accident (CVA), the nurse anticipates the medical treatment to include which of the following? a. Cholesterol-lowering drugs b. Anticoagulant therapy c. Monthly prothrombin levels d. Carotid endarterectomy

b. Anticoagulant therapy

4. When caring for a patient who has had a stroke, a priority is reduction of ICP. What patient position is most consistent with this goal? a. Head turned slightly to the right side b. Elevation of the head of the bed c. Position changes every 15 minutes while awake d. Extension of the neck

b. Elevation of the head of the bed

19. 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? a. Diphenhydramine (Benadryl) b. Lioresal (Baclofen) c. Heparin d. Pregabalin (Lyrica)

b. Lioresal (Baclofen)

18. The nurse is performing stroke risk screenings at a hospital open house. The nurse has identified four patients who might be at risk for a stroke. Which patient is likely at the highest risk for a hemorrhagic stroke? a. White female, age 60, with history of excessive alcohol intake b. White male, age 60, with history of uncontrolled hypertension c. Black male, age 60, with history of diabetes d. Black male, age 50, with history of smoking

b. White male, age 60, with history of uncontrolled hypertension

What is the drug classification of Lorazepam and what is the trade name?

benzodiazepine, Ativan

1. A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take? a. Use one long sentence to say everything that needs to be said. b. Keep the television on while she speaks. c. Talk in a louder than normal voice. d. Face the client and establish eye contact.

d. Face the client and establish eye contact.

A patient with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this patient? A) Range-of-motion exercises to prevent contractures B) Encouraging independence with ADLs to promote recovery C) Early initiation of physical therapy D) Absolute bed rest in a quiet, nonstimulating environment

D) Absolute bed rest in a quiet, nonstimulating environment

A patient recovering from a stroke has severe shoulder pain from subluxation of the shoulder and is being cared for on the unit. To prevent further injury and pain, the nurse caring for this patient is aware of what principle of care? A) The patient should be fitted with a cast because use of a sling should be avoided due to adduction of the affected shoulder. B) Elevation of the arm and hand can lead to further complications associated with edema. C) Passively exercising the affected extremity is avoided in order to minimize pain. D) The patient should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder.

D) The patient should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder.

What should be included in the patient's care plan when establishing an exercise program for a patient affected by a stroke? A) Schedule passive range of motion every other day. B) Keep activity limited, as the patient may be over stimulated. C) Have the patient perform active range-of-motion (ROM) exercises once a day. D) Exercise the affected extremities passively four or five times a day.

D) Exercise the affected extremities passively four or five times a day.

A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the physician in the emergency department. After completing ordered diagnostic tests, the physician indicates to the client what caused the symptoms that brought him to the hospital. What is the origin of the client's symptoms? a) Hypertension b) Cardiac disease c) Diabetes insipidus d) Impaired cerebral circulation

Impaired cerebral circulation TIAs result from impaired blood circulation in the brain, which can be caused by atherosclerosis and arteriosclerosis, cardiac disease, or diabetes. The symptoms of a TIA are the result of impaired blood circulation in the brain, which may have been caused by cardiac disease. The symptoms of a TIA are the result of impaired blood circulation in the brain, which may have been caused by diabetes. The symptoms of a TIA are the result of impaired blood circulation in the brain, which may have been caused by hypertension.

A client is hospitalized when they present 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 their presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what? a) Cerebral aneurysm b) Transient ischemic attack c) Left-sided stroke d) Right-sided stroke

Transient ischemic attack 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.

Following diagnostic testing, a patient has been admitted to the ICU and placed on cerebral aneurysm precautions. What nursing action should be included in patient's plan of care? A) Supervise the patient's activities of daily living closely. B) Initiate early ambulation to prevent complications of immobility. C) Provide a high-calorie, low-protein diet. D) Perform all of the patient's hygiene and feeding.

A) Supervise the patient's activities of daily living closely.

A patient with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the patient's cardiac and neurologic status, the nurse monitors the patient for signs of what complication? A) Acute pain B) Septicemia C) Bleeding D) Seizures

C) Bleeding

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) Transient ischemic attack (TIA) d) Completed Stroke

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. There is not enough information to determine if the stroke is still evolving or is complete.

How long does the typical neurological deficit last with a TIA?

less than 24 hrs, lasting 1-2 hrs

A patient has been admitted to the ICU after being recently diagnosed with an aneurysm and the patient's admission orders include specific aneurysm precautions. What nursing action will the nurse incorporate into the patient's plan of care? A) Elevate the head of the bed to 45 degrees. B) Maintain the patient on complete bed rest. C) Administer enemas when the patient is constipated. D) Avoid use of thigh-high elastic compression stockings.

B) Maintain the patient on complete bed rest.

The nurse is discharging home a patient who suffered a stroke. He has a flaccid right arm and leg and is experiencing problems with urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common patient response to a change in body image? A) Denial B) Fear C) Depression D) Disassociation

C) Depression

The nurse is providing diet-related advice to a male patient following a cerebrovascular accident (CVA). The patient wants to minimize the volume of food and yet meet all nutritional elements. Which of the following suggestions should the nurse give to the patient about controlling the volume of food intake? a) Provide a high-fat diet. b) Include dry or crisp foods and chewy meats. c) Always serve hot or tepid foods. d) Provide thickened commercial beverages and fortified cooked cereals.

Provide thickened commercial beverages and fortified cooked cereals. Patients with CVA or other cerebrovascular disorders should lose weight and therefore should minimize their volume of food consumption. To ensure this, the nurse may provide thickened commercial beverages, fortified cooked cereals, or scrambled eggs. Patients should avoid eating high-fat foods, and serving foods hot or tepid will not minimize the volume consumed by the patient. Foods such as peanut butter, bread, tart foods, dry or crisp foods, and chewy meats should also be avoided because they cause choking.

5. A patient diagnosed with an ischemic stroke should be treated within the first 3 hours of symptom onset with which of the following? a. Clopidogrel b. Extended release dipyridamole c. Tissue plasminogen activator (tPA) d. Atorvastatin

c. Tissue plasminogen activator (tPA)

The patient has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the patient's atmosphere more conducive to communication? A) Provide a board of commonly used needs and phrases. B) Have the patient speak to loved ones on the phone daily. C) Help the patient complete his or her sentences. D) Speak in a loud and deliberate voice to the patient.

A) Provide a board of commonly used needs and phrases.

Which of the following is the most common side effect of tissue plasminogen activator (tPA)? a) Increased intracranial pressure (ICP) b) Hypertension c) Headache d) Bleeding

Bleeding 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.

The nurse is performing stroke risk screenings at a hospital open house. The nurse has identified four patients who might be at risk for a stroke. Which patient is likely at the highest risk for a hemorrhagic stroke? A) White female, age 60, with history of excessive alcohol intake B) White male, age 60, with history of uncontrolled hypertension C) Black male, age 60, with history of diabetes D) Black male, age 50, with history of smoking

B) White male, age 60, with history of uncontrolled hypertension

The nurse is preparing health education for a patient who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in this education? A) Mild, intermittent seizures can be expected. B) Take ibuprofen for complaints of a serious headache. C) Take antihypertensive medication as ordered. D) Drowsiness is normal for the first week after discharge.

C) Take antihypertensive medication as ordered.

The provider diagnoses the patient as having had an ischemic stroke. The etiology of an ischemic stroke would include which of the following? a) Cerebral aneurysm b) Cardiogenic emboli c) Intracerebral hemorrhage d) Arteriovenous malformation

Cardiogenic emboli Aneurysms, hemorrhages, and malformations are all examples of a hemorrhagic stroke. An embolism can block blood flow, leading to ischemia.

Name two more "tips' in communicating with a patient with Aphasia:

2. Face the patient and establish eye contact. 3. Speak in a clear, unhurried manner, and normal tone of voice. 4. Use short phrases, and pause between phrases to allow the patient time to understand what is being said. 5. Limit conversation to practical and concrete matters. 6. Use gestures, pictures, objects, and writing. 7. As the patient uses and handles an object, say what the object is. It helps to match the words with the object or action. 8. Be consistent in using the same words and gestures each time you give instructions or ask a question. 9. 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.

A patient who has experienced an ischemic stroke has been admitted to the medical unit. The patient's family in adamant that she remain on bed rest to hasten her recovery and to conserve energy. What principle of care should inform the nurse's response to the family? A) The patient should mobilize as soon as she is physically able. B) To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks. C) The patient should remain on bed rest until she expresses a desire to mobilize. D) Lack of mobility will greatly increase the patient's risk of stroke recurrence.

A) The patient should mobilize as soon as she is physically able.

Which of the following insults or abnormalities can cause an ischemic stroke? a) Arteriovenous malformation b) Intracerebral aneurysm rupture c) Cocaine use d) Trauma

Cocaine use Cocaine is a potent vasoconstrictor and may result in a life-threatening reaction, even with the individual's first use of the drug. Arteriovenous malformations are associated with hemorrhagic strokes. Trauma is associated with hemorrhagic strokes. Intracerebral aneurysm rupture is associated with hemorrhagic strokes.

A nurse in the ICU is providing care for a patient who has been admitted with a hemorrhagic stroke. The nurse is performing frequent neurologic assessments and observes that the patient is becoming progressively more drowsy over the course of the day. What is the nurse's best response to this assessment finding? A) Report this finding to the physician as an indication of decreased metabolism. B) Provide more stimulation to the patient and monitor the patient closely. C) Recognize this as the expected clinical course of a hemorrhagic stroke. D) Report this to the physician as a possible sign of clinical deterioration.

D) Report this to the physician as a possible sign of clinical deterioration.

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 in complete sentences b) Speaking loudly c) Avoiding the use of hand gestures d) Establishing eye contact

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. (less)

9. An emergency department nurse is interviewing a client with signs of an ischemic stroke that began 2 hours ago. The client reports that she had a cholecystectomy 6 weeks ago and is taking digoxin, coumadin, and labetelol. This client is not eligible for thrombolytic therapy for which of the following reasons? a. She is taking coumadin. b. She is not within the treatment time window. c. She is taking digoxin. d. She had surgery 6 weeks ago

a. She is taking coumadin.

The nurse is caring for a patient recovering from an ischemic stroke. What intervention best addresses a potential complication after an ischemic stroke? A) Providing frequent small meals rather than three larger meals B) Teaching the patient to perform deep breathing and coughing exercises C) Keeping a urinary catheter in situ for the full duration of recovery D) Limiting intake of insoluble fiber

B) Teaching the patient to perform deep breathing and coughing exercises

The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regime, 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: a) Dyslipidemia b) Obesity c) Hypertension d) Smoking

Hypertension Hypertension is the most modifiable risk factor for either ischemic or hemorrhagic stroke. Unfortunately, it remains under-recognized and undertreated in most communities.

Name three modifiable risk factors for an Ischemic Stroke.

• Asymptomatic carotid stenosis • Atrial fibrillation • Diabetes (associated with accelerated atherogenesis) • Dyslipidemia • Excessive alcohol consumption • Hypercoagulable states • Hypertension (controlling hypertension, the major risk factor, is the key to preventing stroke) • Migraine • Obesity • Sedentary lifestyle • Sleep apnea • Smoking

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? a) "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." b) "Clinical manifestations of a stroke generally include aphasia, one-sided flaccidity, and trouble swallowing." c) "Clinical manifestations of a stroke depend on how quickly the clot can be dissolved." d) "Clinical manifestations of a stroke are highly variable, depending on the cardiovascular health of the client."

"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.) Clinical manifestations of a stroke do not depend on the cardiovascular health of the client or how quickly the clot can be dissolved. Clinical manifestations of a stroke are not "general" but individual.

A nurse is caring for a patient diagnosed with a hemorrhagic stroke. When creating this patient's plan of care, what goal should be prioritized? A) Prevent complications of immobility. B) Maintain and improve cerebral tissue perfusion. C) Relieve anxiety and pain. D) Relieve sensory deprivation.

B) Maintain and improve cerebral tissue perfusion.

The nurse is caring for a patient diagnosed with an ischemic stroke and knows that effective positioning of the patient is important. Which of the following should be integrated into the patient's plan of care? A) The patient's hip joint should be maintained in a flexed position. B) The patient should be in a supine position unless ambulating. C) The patient should be placed in a prone position for 15 to 30 minutes several times a day. D) The patient should be placed in a Trendelenberg position two to three times daily to promote cerebral perfusion.

C) The patient should be placed in a prone position for 15 to 30 minutes several times a day.

7. The nurse is reviewing the medication administration record of a female patient who possesses numerous risk factors for stroke. Which of the woman's medications carries the greatest potential for reducing her risk of stroke? a. Naproxen 250 PO b.i.d. b. Calcium carbonate 1,000 mg PO b.i.d. c. Aspirin 81 mg PO o.d. d. Lorazepam 1 mg SL b.i.d. PRN

c. Aspirin 81 mg PO o.d.

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? a) Footdrop and external hip rotation b) Vomiting and seizures c) Severe headache and early change in level of consciousness d) Weakness on one side of the body and difficulty with speech

Weakness on one side of the body and difficulty with speech The main presenting symptoms for an 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. Footdrop and external hip rotation are things that can occur if a stroke victim is not turned or positioned correctly.

Which of the following is a contraindication for the administration of tissue plasminogen activator (t-PA)? a) Systolic blood pressure less than or equal to 185 mm Hg b) Ischemic stroke c) Intracranial hemorrhage d) Age 18 years of age or older

Intracranial hemorrhage Intracranial hemorrhage, neoplasm, or aneurysm is a contraindication to t-PA. Clinical diagnosis of ischemic stroke, age 18 years of age or older, and a systolic BP less than or equal to 185 mm Hg are eligibility criteria. (less)

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? a) Limited attention span and forgetfulness b) Visual agnosia c) Auditory agnosia d) Lack of deep tendon reflexes

Lack of deep tendon reflexes Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia. 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 lack of motivation. Damage to the lower motor neurons may cause decreased muscle tone, flaccid muscle paralysis, and a decrease in or loss of reflexes.

When caring for a patient who had a hemorrhagic stroke, close monitoring of vital signs and neurologic changes is imperative. What is the earliest sign of deterioration in a patient with a hemorrhagic stroke of which the nurse should be aware? A) Generalized pain B) Alteration in level of consciousness (LOC) C) Tonic-clonic seizures D) Shortness of breath

B) Alteration in level of consciousness (LOC)

17. 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. Elevating the head of the bed at 30 degrees b. Monitoring for seizure activity c. Administering a stool softener d. Maintaining a patent airway

d. Maintaining a patent airway

A rehabilitation nurse caring for a patient who has had a stroke is approached by the patient's family and asked why the patient has to do so much for herself when she is obviously struggling. What would be the nurse's best answer? A) "We are trying to help her be as useful as she possibly can." B) "The focus on care in a rehabilitation facility is to help the patient to resume as much self-care as possible." C) "We aren't here to care for her the way the hospital staff did; we are here to help her get better so she can go home." D) "Rehabilitation means helping patients do exactly what they did before their stroke."

B) "The focus on care in a rehabilitation facility is to help the patient to resume as much self-care as possible."