Chapter questions: STROKE
Four days following a stroke, a pt is to start oral fluids and feedings. Before feeding the pt, what should the nurse do first? A. Check the pt's gag reflex B. Order a soft diet for the pt C. Raise the head of the bed to a sitting position D. Assess the pt's ability to swallow tiny amounts of crushed ice.
A. usually the speech therapist will have completed a swallowing before a diet is ordered. The first step in providing oral feedings for a pt w/ a stroke is ensuring that that the pt has an intact gag reflex b/c oral feedings will not be provided if the gag reflex is impaired. After placing the pt in an upright position, the nurse may then evaluate the pt's ability to swallow w/ ice chips or water.
During the secondary assessment of the patient w/ a stroke, what should be included? SATA A. Gaze B. Sensation C. Facial palsy D. Proprioception E. Current medications F. Distal motor function
A, B, C, D, F The secondary assessment and ongoing neurologic monitoring including the gaze, sensation, facial palsy, proprioception, distal motor function, cognition, motor abilities, cerebellar function, and deep tendon reflexes. Current medications and Hx of HTN are part of the primary assessment.
Which statements describe characteristics of a stroke caused by an intracerebral hemorrhage? SATA A. Carries a poor prognosis B. Caused by rupture of a vessel C. Strong association w/ HTN D. Commonly occurs during or after sleep E. Creates a mass that compresses the brain
A, B, C, E Strokes from intracerebral hemorrhage have a poor prognosis, are caused by the rupture of a blood vessel, are associated w/ HTN and may create a mass that compresses the brain. HTN is also r/t thrombotic strokes that often occur during sleep or after sleep.
A nurse is assessing a client. Which of the following findings indicates that the client has experienced a left-hemispheric stroke? A. Impulsive control difficulty B. Poor judgement C. Inability to recognize familiar objects D. Loss of depth perception
A. A client who has experienced a RIGHT-hemispheric stroke will experience difficulty w/ impulsive control. B. A client who has experienced a RIGHT-hemispheric stroke will experience poor judgement C. A client who experienced a left-hemispheric stroke will demonstrate the inability to recognize familiar objects, known as agnosia. D. A client who experienced a RIGHT-hemispheric stroke will experience a loss of depth perception.
A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention? A. Teach the client to scan to the right to see objects on the right side of the body. B. Place the bedside table on the right side of the bed. C. Orient the client to the food on the plate using the clock method. D. Place the wheelchair on the client's left side
A. A client who has left homonymous hemianopsia has lost the left visual field of both eyes. The client should be taught to turn the head to the left to visualize the entire field of vision. B. The client is unable to visualize to the left midline of their body. Placing the bedside table on the right side of the client's bed will permit visualization of items on the table. C. Using the clock method of food placement will be ineffective b/c only half of the plate can be seen. D. The wheelchair should be placed to the client's right side or unaffected side.
A nurse is caring for a client who has global aphasia (both receptive and expressive). Which of the following should the nurse include in the client's plan of care? A. Speak to the client at a slower rate. B. Assist the client to use cards w/ pictures. C. Speak to the client in a loud voice. D. Complete sentences that the client cannot finish. E. Give instructions one step at a time.
A. Clients who have global aphasia have difficulty w/ speaking and understanding speech. One strategy that can enhance client understanding is speaking to the client at a slower rate. B. One strategy that can enhance understanding is the use of alternative forms of communication, such as cards w/ pictures or a computer. C. For the client who has aphasia, speaking in a loud voice is unnecessary and can be interpreted as patronizing. D. Allow the client adequate time to finish sentences and not complete the sentences for them. E. One strategy that can enhance understanding is giving instructions one step at a time.
Which type of stroke is associated w/ endocardial disorders, has a rapid onset and is likely to occur during activity? A. Embolic B. Thrombotic C. Intracerebral hemorrhage D. Subarachnoid hemorrhage
A. Embolic strokes are associated w/ endocardial disorders, such as A-fib, have a rapid onset, and are likely to occur during activity. Hemorrhage also commonly occurs during activity but is unrelated to cardiac disorders.
A nurse is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care? (SATA) A. Have suction available for use B. Feed the client thickened liquids C. Place food on the unaffected side of the client's mouth D. Assign an assistive personnel to feed the client slowly E. Teach the client to swallow w/ neck flexed
A. Suction equipment should be available in case of choking and aspiration B. The client should be given liquids that are thicker than water to prevent aspiration C. Placing food on the unaffected side of the client's mouth will allow them to have better control of the good and reduce the risk of aspiration. D. Due to the risk of aspiration, assistive personnel should should not be assigned to feed the client b/c the client's swallowing ability should be assessed and suctioning can be needed if choking occurs. E. The client should be taught to flex the neck, tucking the chin down and under to close the epiglottis during swallowing.
During the acute phase of a stroke, the nurse assesses the pt's vital signs and neurologic status at least every 4 hours. What is a cardiovascular sign that the nurse would see as the body attempts to increase cerebral blood flow? A. HTN B. Fluid overload C. Cardiac dysrhythmias D. S3 and S4 heart sounds
A. The body responds to the vasospasm and decreased circulation to the brain that occurs with a stroke by increasing the BP, frequently resulting in HTN. The other options are important cardiovascular factors to assess, but they do not result from impaired cerebral blood flow.
A nurse is caring for a client who has experienced a right-hemispheric stroke. The nurse should expect the client to have difficulty with which of the following? A. Impulsive Control B. Moving the left side C. Depth perception D. Speaking E. Situational awareness
A. a client who has experienced a right hemispheric stroke can exhibit impulse control difficulty, such as urgency to use the restroom B. A client who has experienced a right-hemispheric stroke can exhibit left-sided hemiplegia C. A client who has experienced a right- hemispheric stroke can experience a loss in depth perception D. A client who has experienced a LEFT-hemispheric stroke can experience aphasia. E. A client who experienced a right-hemispheric stroke can demonstrate a lack of awareness of surroundings.
What is an appropriate nursing intervention to promote communication during rehab of the pt with aphasia? A. Allow time for the individual to complete his/her thoughts. B. Use gestures, pictures, and music to stimulate pt responses. C. Structure statements so that the pt doe snot have to respond verbally D. Use flashcards w/ simple words and pictures to promote recall of language
A. during rehab, the pt w/ aphasia needs time to process and complete thoughts for verbal response. Conversation by the nurse and family should include meaningful verbal stimulation that is relevant to the pt. Gestures, pictures, and simple statements may be overwhelmed by verbal stimuli. Not responding verbally does not promote communication. Flashcards are often perceived by the pt as childish and meaningless.
A newly admitted pt diagnosed w/ a right-sided brain stroke has homonymous hemianopsia. Early in the care of the patient, what should the nurse do? A. Place objects on the right side within the pt's field of vision. B. Approach the pt from the left side to encourage the pr to turn the head. C. Place objects on the pt's left side to assess the pt's ability to compensate. D. Patch the affected eye to encourage the pt to turn the head to scan the environment.
A. the presence of homonymous hemianopia in a pt w/ right hemisphere brain damage causes a loss of vision in the left field bilaterally. Early in the care of the pt, objects should be placed on the right side of the pt in the field of vision, and the nurse should approach the pt from the right side. Later in the treatment, pt's should be taught to turn the head and scan the environment and should be approached from the affected side side encourage head turning. Eye patches are used if pt's have diplopia. (double vision)
The rehabilitation nurse assesses the pt, caregiver, and family before planning the rehab program for this patient. What must be included in this assessment? SATA A. Cognitive status of the family B. Pt resources and support C. Physical status of all body systems D. Rehabilitation potential of the pt E. Body strength remaining after the stroke F. Patient and caregiver expectations of the rehab
C, D, F. The pt's rehabilitation potential, physical status of all body systems, and the expectations of the pt and caregiver r/t the rehab program will have a big impact on planning and carrying out the rehab plan. The other things the rehab nurse will assess are the presence of complications caused by the stroke or other chronic conditions, the pr's cognitive status, and the family (including the pt and caregiver) resources and support.
What primarily determines the neurologic functions that are affected by a stroke? A. The amount of tissue area involved B. The rapidity of the onset of Sx C. The brain area perfused by the affected artery D. The presence or absence of collateral circulation
C. Clinical manifestations of altered neurologic function differ, depending primarily on the specific cerebral artery involved and the area of the brain that is perfused by the artery. The prognosis is r/t the amount of brain tissue involved. The degree of impairment depends on rapidity of the onset, the size of the lesion, and the presence of collateral circulation.
A pt is admitted to the hospital w/ left hemiplegia. To determine the size and location and to ascertain whether a stroke is ischemic or hemorrhagic, what will the nurse anticipate that the HCP will request? A. Lumbar puncture B. Cerebral angiography C. MRI D. CT scan w/ contrast
C. MRI could be used to rapidly distinguish between ischemic and hemorrhagic stroke and determine the size and location of the lesion. A NON contrast CT can could also be used. Lumbar punctures are not performed routinely b/c of the chance of increased ICP causing herniation. Cerebral arteriograms are invasive and may dislodge an embolism or cause further hemorrhage. They are performed only when no other test can provide the needed information.
Which intervention can the nurse delegate to the LPN when caring for a patient following an acute stroke? A. Assess the pt's neurologic status B. Assess the pt's gag reflex before beginning feeding C. Administer ordered antihypertensives and platelet inhibitors D. Teach the pt's caregivers strategies to minimize unilateral neglect
C. Medication administration is within the scope of practice for the RN.
The patient has a lack of comprehension of both verbal and written language. Which type of communication difficulty does this pt have? A. Dysarthria B. Fluent dysphasia C. Receptive aphasia D. Expressive aphasia
C. Receptive aphasia is the lack of comprehension of both verbal and written language. - Dysarthria is disturbance in muscular control of speech. - In fluent dysphasia, speech is present but contains little meaningful communication. - Expressive aphasia is the loss of the production of language.
What is an appropriate food for a pt w/ a stroke who has mild dysphagia? A. Fruit juices B. Pureed meat C. Scrambled eggs D. Fortified milkshakes
C. Soft foods that provide enough texture, flavor and bulk to stimulate swallowing should be used for the pt w/ dysphagia. Thin liquids are difficult to swallow, and pt's may not be able to control them in the mouth. Pureed foods are often too bland and too smooth, and milk products should be avoided b/c they tend to increase the viscosity of mucus and increase salivation.
A thrombus that develops in a cerebral artery does not always cause a loss of neurologic function b/c A. the body an dissolve atherosclerotic plaques as they form B. some tissues of the brain do not require constant blood supply to prevent damage. C. Circulation via the Circle of Willis may provide blood supply to prevent damage. D. Neurologic deficits occur only when major arteries are occluded by thrombus formation around atherosclerotic plaques.
C. The communication between the anterior and posterior cerebral circulation in the circle of Willis provides a collateral circulation, which may maintain circulation to an area of the brain if its original blood supply is obstructed. Atherosclerotic plaques are not readily reversed, and all areas of the brain require constant blood supply. Neurologic deficits can result from ischemia caused by many factors.
Med Surg Book: In promoting health maintenance for prevention of strokes, the nurse understands that the highest risk for the most common type of stroke is present in which people? A. Blacks B. Women who smoke C. Persons w/ HTN ad DM D. Those who are obese w/ high dietary fat intake
C. The highest risk factors for the most common stroke, thrombotic stroke are HTN and DM. Blacks have a higher risk for stroke then do white persons, probably b/c they have a greater incidence of HTN, DM, and obesity. Factors such as diet high in saturated fats and cholesterol, cigarette smoking, metabolic syndrome, sedentary lifestyle, and excessive alcohol use are also risk factors but carry less risk than HTN.
A pt w/ a stroke has a right-sided hemiplegia. What does the nurse teach the family to prepare them to cope with the behavior changes seen with this type of stroke? A. Ignore undesirable behaviors manifested by the pt B. Provide directions to the pt verbally in small steps C. Distract the pt from inappropriate emotional responses. D. Supervise all activities before allowing the pt do them independently.
C. pt's with left brain damage from stroke often experience emotional lability, inappropriate emotional responses, mood swings, and uncontrolled tears or laughter disproportionate to or out of context w/ the situation. The behavior is upsetting and embarrassing to both the pt and family, and the pt should be distracted to minimize its presence. Maintaining a calm environment and avoiding shaming or scolding the pt are important. Pt's w/ right-brain damage often have impulsive, rapid behavior that requires supervision and direction.
A pt with a right-hemisphere stroke has unilateral neglect. During the pt's rehab, what nursing intervention is important for the nurse to do? A. Avoid positioning the pt on the affected side B. Place all objects for care on the pt's unaffected side C. Teach the pt to care consciously for the affected side D. Protect the affected side from injury w/ pillows and supports
C. unilateral neglect, or neglect syndrome, occurs when the pt w/ a stroke is unaware of the affected side of the body, which puts the pt at risk for injury. During the acute phase, the affected side is cared for by the nurse with positioning and support, but during rehab the pt is taught to care consciously for and attend to the affected side of the body to protect it from injury. Pt's may be positioned on the affected side for up to 30 min.
A pt's wife asks the nurse why her husband did not receive the clot-busting medication (tissue plasminogen activator (TPA) she has been reading about. Her husband is diagnosed with a hemorrhagic stroke. what is the best response by the nurse to the pt's wife? A. "He didn't arrive within the time frame for that therapy" B. "Not everyone is eligible for this drug. HAs he had surgery lately?" C. "You should discuss the treatment of your husband w/ his doctor. D. "The medication you are talking about dissolves clots and could cause more bleeding in your husband's brain."
D. Recombinant tissue plasminogen activator (tPA) dissolves clots and increases the risk for bleeding. It is not used w/ hemorrhagic strokes. If the pt had a thrombotic or embolic stroke, the timeframe of 3 to 4.5 hours after onset of clinical signs of the stroke would be important as well as a Hx of surgery. The nurse should answer the question as accurately as possible and then encourage the wife to talk w/ the HCP if she has further questions.
What is the priority intervention in the ED for the patient with a stroke? A. IV fluids replacement B. Giving osmotic diuretics to reduce cerebral edema C. Starting hypothermia to decrease the oxygen needs of the brain D. Maintaining respiratory function w/ a patent airway and oxygen administration
D. The first priority in acute management of the pt w/ a stroke is preservation of life. B/c the pt with a stroke may by unconscious or have a reduced gag reflex, it is most important to maintain a patent airway for the pt and provide oxygen if respiratory effort is impaired. IV fluid replacement, treatment w/ osmotic diuretics, and avoiding hyperthermia may be used for further treatment depending on the pt's manifestations.
The nurse can best assist the pt and family in coping w/ the long term effects of a stroke by doing what? A. Informing family members that the pt will need assistance w/ almost all activities of daily living (ADLs) B. Explaining that the pt's pre-stroke behavior will return as improvement progresses. C. Encouraging the pt and family members to seek assistance from family therapy or stroke support groups D. Helping the pt and family understand the significance of residual stroke damage to promote problem solving and planning
D. The pt and family need accurate and complete information about the effects of the stroke to problem solve and make plans for chronic care of the pt. The pt's specific needs for care must be identified and rehab efforts should be continued at home. It is uncommon for pt's with major strokes to return completely to pre-stroke function, behaviors, and role. Both the patient and family will mourn these losses. Family therapy and support groups may be helpful for some pt's and family.
A pt comes to the ED w/ numbness of the face and an inability to speak. While the pt awaits examination, the sx disappear and the pt requests discharge. Why should the nurse emphasize that it is important for the pt to be treated before leaving? A. The pt has probably experienced an asymptomatic lacunar stroke B. The sx are likely to return and progress to worsening neurologic deficit in the next 24 hours. C. Neurologic deficits that are transient occur most often as a result of small hemorrhages that clot off. D. The pt has probably had a transient ischemic attack (TIA), which is a sign of progressive cerebrovascular disease
D. a TIA is a temporary focal loss of neurologic function caused by ischemia of an area of the brain, usually lasting an hour or less. TIAs may be caused by microemboli that temporarily block blood flow and are a warning of progressive cerebrovascular disease. Evaluation is necessary to determine the cause of the neurologic deficit and provide prophylactic treatment if possible.
A carotid endarterectomy is being considered as treatment for a patient who has had several TIAs. What should the nurse explain to the pt about this surgery? A. It involves intracranial surgery to join a superficial extracranial artery to an intracranial artery B. It is used to restore blood circulation to the brain following an obstruction of a cerebral artery. C. It is used to open a stenosis in a carotid artery w/ a balloon and stent to restore cerebral circulation. D. It involves removing an atherosclerosis plaque in the carotid artery to prevent an impending stroke.
D. a carotid endarterectomy is the removal of an atherosclerotic plaque in the carotid arteries that may impair circulation enough to cause a stroke. The other procedures described may also be used to prevent strokes. An extracranial-intracranial bypass involves cranial surgery to bypass a sclerotic intracranial artery. Stenting may improve circulation in the brain. A percutaneous transluminal angioplasty uses a balloon to compress stenotic areas in the carotid and vertebrobasilar arteries and often includes inserting a stent to hold the artery open.
What is a nursing intervention that is indicated for the pt with hemiplegia? A. The use od a footboard to prevent plantar flexion B. Immobilization of the affected arm against the chest w/ a sling C. Positioning the pt in bed w/ each joint lower then the joint proximal to it D. Having the pt perform passive ROM of the affected limb with the unaffected limb
D. active ROM should be started on the unaffected side asap. Passive ROM of the affected side should be started on the first day. Having the pt actively exercise the unaffected sides provides the pt with active and passive ROM as needed. Use of footboards is controversial b/c they stimulate plantar flexion. The unaffected arm should be supported, but immobilization may precipitate a painful shoulder-hand syndrome. The pt should be positioned w/ each joint higher than the joint proximal to it to prevent dependant edema.
The incidence of ischemic stroke n pt's with TIAs and other risk factors is reduced with the administration of which medication? A. Nimodipine B. Furosemide C. Warfarin D. Daily low-dose aspirin
D. administering antiplatelet agents, such as aspirin, ticlopidine, clopidogrel (Plavix), dipyridamole (Persantine), and combined dipyridamole and aspirin (Aggrenox), reduces the incidence of stroke in those at risk. - Anticoagulants are used for prevention of embolic strokes but increase the risk for hemorrhage. The calcium channel blocker, nimodipine, is used in pt's w/ subarachnoid hemorrhage to decrease the effects of vasospasm and minimize tissue damage. Diuretics are not used for stroke prevention other than for their role in controlling BP. Warfarin, although it is an anticoagulant, is used for pt's w/ A-fib not TIA.
Seen in left brain damage:
- Aphasia - Inability to remember words - Hemiplegia of the right side of the body
Seen in Right brain damage
- Impaired judgement - Quick, impulsive behavior - Left homonymous hemianopsia - Neglect of the left side of the body
A diagnosis of a ruptured cerebral aneurysm has been made in a pt with manifestations of a stroke. The nurse anticipates which treatment option that would be considered for the pt? A. Hyperventilation therapy B. Surgical clipping of the aneurysm C. Administration of hyperosmotic agents D. Administration of thrombolytic therapy
B. Surgical management with clipping of an aneurysm to decrease rebleeding and vasospasm is an option for a stroke caused by rupture of a cerebral aneurysm. Placement of coils provides immediate protection against hemorrhage by reducing the blood pulsations within the aneurysm , then a thrombus forms and the potential for hemorrhage. Osmotic diuretics may leak into tissue, pulling fluid out of the vessel and increasing edema. Thrombolytic therapy would be absolutely contraindicated.