CVA Review
TIA is also called a
"mini stroke", "silent stroke" or a reversible ischemic neurological deficit
TIA
- temporary episode of neurologic dysfunction manifested by sudden loss of motor, sensory, or visual function
Predisposing risk factors for a TIA and possible stroke
-History of tobacco use for 25 years -Husband smokes one pack per day -Sedentary lifestyle/ Physical inactivity -High total cholesterol; low HDL cholesterol. Normal values (Total cholesterol < 200, HDLs 40mg/dL or higher, LDL less than 100mg/ dL). -Ethnicity (African American). -Heredity (Positive family history of heart disease). -Gender -Stroke is more common in men than women, however women account for more than half of all stroke-related deaths. -Age (59 years old). Increased age increases risk of stroke in men 45 years or older and in women 55 years or older
Hemianopsia
Loss of half of the visual field in one or both eyes
During TIA what is released
Micro emboli are released from a thrombus causing a temporary in blood flow
The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? a.An oral anticoagulant medication. b.A beta-blocker medication c. An anti-hyperuricemia medication. d.A thrombolytic medication.
a
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
The client is diagnosed with expressive aphasia. Which psychological problem would the nurse include in the plan of care? a.Potential for injury . b.Powerlessness. c.Disturbed thought process. d.Sexual dysfunction.
b
Diplopia
double vision
How do you expect the pupils to respond with a stroke/ brain injury?
fixed and dilated
The client with TIA is symptomatic
for less than 24 hours
Difference between a TIA and a CVA
is that a TIA involves a short duration of interrupted blood flow to an area of the brain and does not usually result in permanent deficits
Amaurosis
loss of sight without any transparent lesion of the eye resulting from disease of the optic nerve, spine or brain
Most common cause TIA
thromboembolism from ulcerated plaque within the carotid arteries (Other sources include emboli forming on diseased or prosthetic heart valves, A-Fib, or breakdown of plaque)
Which client would the nurse identify as being most at risk for experiencing a CVA? a.A 55-year-old African American male. b.An 84-year-old Japanese female. c.A67-year-old Caucasian female. d.A 39-year-old pregnant female.
a
A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement? a.Administer a stool softener BID. b.Encourage the client to cough hourly. c.Monitor neurological status every shift. d.Maintain a dopamine drip to keep the BP at 160/90.
a (reduces intercranial pressure due to straining)
Ataxia
a decrease, failure, or irregularity of a person's muscular coordination
After having a stroke, a patient has cognitive deficits. What are the cognitive deficits the nurse recognizes the patient has as a result of the stroke? (Select all that apply) a. Poor abstract thinking b. Decreased attention span c. Short- and long-term memory loss d. Expressive aphasia e. Paresthesia
a,b,c,d
The client is diagnosed with a right-sided cerebrovascular accident is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply. a.Position the client to prevent shoulder adduction. b. Turn and position the client every shift. c. Encourage to client to move to the affected side. d. Provide resources for support groups. e. Instruct the client to hold the fingers in a fist.
a,c,d
TIA is caused by a
brief interruption in blood flow, possibly from a cerebral vasospasm or transient systemic arterial hypertension
A 78-year -old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority? a. Prepare to administer recombinant tissue Plasminogen activator (rt-PA). b. Discuss the precipitating factors that caused the symptoms. c. Schedule for a STAT computed tomography (CT) scan of the head. d. Notify the speech pathologist for the emergency consult.
c
A patient is brought to the emergency department experiencing a possible stroke. What initial diagnostic test for a stroke, usually performed in the emergency department, would the nurse prepare the patient for? a. 12-lead electrocardiogram. b. Carotid ultrasound study. c. Non-Contrast computed tomography d. Transcranial Doppler flow study
c
Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke. a.A blood glucose level of 480mg/dL. b.A right-sided carotid bruit. c.A blood pressure of 220/120mm HG. d.The presence of bronchogenic carcinoma.
c
An 85-year-old client diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first? a.Administer a non-narcotic analgesic. b.Prepare for a STAT magnetic resonance imaging (MRI). c.Start an intravenous line with D5W at 100ml/hr. d.Complete a neurological assessment.
d
The nurse recognizes that the patient is exhibiting stroke symptoms associated with a TIA. After what period does the nurse determine that these symptoms will subside? a. 1 hour b. 3-6 hours c. 12 hours d. 24-46 hours
d
When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke? a. The day before the patient is discharged. b. After the patient has passed the acute phase of the stroke c. After the nurse has received the discharge orders. d. The day the patient had the stroke.
d
