Med Surg 1 Ch45 Adaptive Quizzing
A family member of a patient who experienced a stroke is anxious and says to the nurse, "Something is the matter with Grandpa. All he does is cry!" Which response by the nurse is best at this time?
"He is emotionally labile and may have this behavior for some time." "It sounds like he is depressed, so I will inform the provider." If the frontal lobe has been injured by a stroke, the patient may experience emotional lability in which the patient laughs then cries, most often for no apparent reason. It is an uncontrollable response and should be explained to the family. Hemianopsia leads to neglect of one side of the body. Crying is not a symptom of brain stem deterioration, which would include respiratory problems, and it is not an exclusive symptom of depression.
A patient who sustained a transient ischemic attack (TIA) is admitted to emergency department. The nurse is teaching the student nurse about methods to prevent another TIA. Which statement made by the student nurse indicates a need for further teaching?
"The patient should be placed on a totally liquid diet." It is not necessary for the patient to maintain a totally liquid diet. The patient can eat any food that is healthy for the heart. Aspirin is an antiplatelet drug that prevents platelet aggregation and clot formation. Patients who sustain a TIA have high blood pressure; therefore, it is important to give antihypertensive medications in order to maintain a normal blood pressure. Oral hypoglycemic medications should be given to the patient to maintain blood sugar levels in the normal range, thereby preventing another attack.
How much time will it take for the symptoms of transient ischemic attack to resolve?
30-60 minutes Ischemic strokes often follow warning signs such as a transient ischemic attack (TIA). Symptoms of a TIA resolve within 30 to 60 minutes. TIA is a transient episode and may not last for more than an hour.
Which ethnic group has the highest prevalence of stroke over others?
American Indians and Alaskan Natives American Indian/Alaskan Native groups have the highest prevalence of stroke. African-American men and women have more strokes than Caucasian men and women. Hispanic or Latino men have more strokes than non-Hispanic men. The causes for these differences are not well known, but genetic, environmental, and/or lifestyle factors may play a role, including dietary habits.
What is the most common complication of dysphagia?
Aspiration Aspiration is a frequent complication for patients with dysphagia. Many of these aspirations are "silent" and are not recognized until pulmonary complications occur. Choking and vomiting can occur with dysphagia, but are not as common as aspiration.
A patient has been admitted to the hospital with symptoms of an embolic stroke. What etiologic factor in the patient's history places the patient at particular risk for this type of stroke?
Atrial fibrillation The source of most embolic strokes is typically the heart. Emboli occur in patients with a history of atrial fibrillation, ischemic heart disease, or myocardial infarction. Diabetes, aortic aneurysm, and irritable bowel disease are not primary risk factors.
Which statement best characterizes the manifestation of symptoms of a transient ischemic attack (TIA)?
They typically resolve within 30-60 minutes Symptoms of a TIA typically resolve within 30-60 minutes. Manifestations can occur in upper and lower extremities and are not limited to the speech area.
The nurse is teaching a patient and family about home care after a stroke. Which statement made by the patient's spouse indicates a need for further teaching?
"I should spend all my time with my husband in case I'm needed. Family members can start to feel socially isolated when caring for a loved one. The family may need to plan for regular respite care in a structured daycare respite program or through relief provided by a friend or neighbor. The life changes associated with stroke often cause a change in the patient's self-esteem. The patient who has had a stroke should maintain a regular medication regimen, such as anticoagulant therapy, to prevent another stroke. Once the home health nurse has assessed the home environment, he or she will notify the health care provider of the need for ancillary services, such as a physical therapist. The physical therapist will identify adaptive equipment needs, will request them, and then will instruct the patient about their use, along with developing an exercise program.
Damage to which cranial nerve (CN) would lead to facial paralysis in the patient?
CN Vll Damage to CN VII would be responsible for facial paralysis. Damage to CN IX interferes with the gag reflex. Damage to CN XII leads to impaired tongue movement. CN IX and X damage can cause an inability to swallow.
A patient diagnosed with a stroke is receiving recombinant tissue plasminogen activator (rtPA) through one intravenous line. The nurse discovers that the second line has infiltrated and removes it. The insertion site continues to bleed even after the nurse applies pressure on it. What is the priority nursing action?
Discontinue the rtPA infusion Recombinant tissue plasminogen activator (rtPA) is a fibrinolytic agent, used for the treatment of ischemic or embolic stroke. Bleeding is a side effect of this medication caused by its pharmacotherapeutic action. Therefore, if the nurse observes any bleeding that is not easily controlled, then the rtPA infusion should be stopped immediately to prevent complications. Increasing the rtPA infusion may cause uncontrolled hemorrhage. The vital signs can be taken and the primary health care provider can be informed after stopping the infusion. Once the infusion is stopped, a pressure bandage should be applied on the puncture site to control the bleeding.
A patient experienced a stroke that caused damage to Broca's area. The nurse expects the patient to experience what phenomenon as a result of this injury?
Expressive aphasia The patient with damage to Broca's area will experience expressive aphasia, which is the result of damage to Broca's area of the frontal lobe; it is a motor speech problem in which the patient generally understands what is being said but cannot communicate verbally. Writing skills are also affected. Rote speech and automatic speech such as responses to a greeting are often intact. Receptive aphasia is due to injury involving Wernicke's area in the temporoparietal area; patients cannot understand the spoken and often the written word, and language is often meaningless. Dysarthria is due to a loss of motor function to the tongue or to the muscles of speech, causing facial weakness and slurred speech. Patients with damage to Broca's area will not experience stuttering.
Which action by unlicensed assistive personnel (UAP) in caring for a patient after a stroke requires immediate intervention by the nurse?
Gently pulling on a patient's flaccid arm to assist the patient up in bed UAP should avoid pulling on an affected or flaccid arm because it could result in subluxation or injury. Turning the patient's plate and using pictures are appropriate actions by UAP. It is appropriate (and correct) for UAP to tell the family that the patient may experience emotional lability after a stroke.
Which substances does the brain require continuously because the brain does not have the ability to store them? Select all that apply.
Glucose and Oxygen The brain cannot store oxygen or glucose; therefore, it must receive a constant flow of blood to provide these substances to maintain normal function.
The nurse is providing discharge teaching to a patient who had a carotid stent placement. The nurse instructs the patient to contact the health care provider at the occurrence of which symptoms? Select all that apply.
Headache Muscle weakness Neck swelling Severe neck pain A patient who is post-carotid stent placement should immediately report symptoms of headache, change in brain function, muscle weakness, neck pain and swelling, and hoarseness because they may be indicative of a potential stroke. Weight gain and constipation are not indicators of significant complications of endarterectomy.
. A 70-year-old woman brought to the emergency department is diagnosed with acute ischemic stroke with a NIH Stroke Scale score of 20. A family member reports last seeing the patient as normal (LSN) 3.5 hours before evaluation. The patient has an INR of 1.4. The nurse anticipates that the patient will not be eligible for fibrinolytic therapy for which reason?
INR 1.4 Guidelines for treatment with fibrinolytic therapy recommend administering the treatment within 4.5 hours of LSN, unless the patient is over 80 years old, has a National Institutes of Health Stroke Scale score greater than 25, or an INR less than or equal to 1.7. While females do not receive fibrinolytic therapy at the same rate as males, female gender is not a contraindication.
. The patient is admitted with a diagnosis of stroke in the right cerebral hemisphere. Upon assessment, which primary deficit does the nurse expect to find?
Impaired proprioception Strokes that occur in the right hemisphere involve visual and special awareness and proprioception. The patient may also be disoriented to place and time. Agraphia (difficulty writing), aphasia (inability to use or comprehend language), and alexia (reading problems) are deficits associated with strokes that occur in the left hemisphere.
The patient is admitted with a diagnosis of stroke in the right cerebral hemisphere. Upon assessment, which primary deficit does the nurse expect to find?
Impaired proprioception Strokes that occur in the right hemisphere involve visual and special awareness and proprioception. The patient may also be disoriented to place and time. Agraphia (difficulty writing), aphasia (inability to use or comprehend language), and alexia (reading problems) are deficits associated with strokes that occur in the left hemisphere.
A patient is brought to the emergency department with sudden onset of right-sided paralysis and difficulty speaking. A family member is worried that these symptoms will be permanent. Based on the patient's symptoms, the nurse anticipates which outcome?
Improvement over several days Embolic strokes have a sudden onset of symptoms that include paralysis and expressive aphasia and tend to resolve over hours to days. Transient ischemic attacks resolve quickly, within 24 hours. Thrombotic strokes have a slower onset and resolve more slowly, sometimes taking weeks to months. Permanent deficits may occur with thrombotic strokes.
A patient has been admitted with a diagnosis of stroke (brain attack). The nurse suspects that the patient has had a right hemisphere stroke because the patient exhibits which symptoms?
Impulsiveness and smiling Impulsiveness and smiling are symptoms indicative of a right hemisphere stroke. Aphasia, cautiousness, quick anger, frustration, and the inability to discriminate words are symptoms indicative of a left hemisphere stroke.
Which nursing intervention takes priority in a patient with dysphagia?
Keep the patient on strict NPO status until he or she can swallow safely The nurse should ensure that the patient remains completely NPO until the speech pathologist determines the patient can safely tolerate liquids or foods without aspirating.
A patient is brought to the emergency department with aphasia and right-sided hemiplegia. The nurse suspects a stroke in which area of the brain?
Left Cerebral hemisphere The left cerebral hemisphere is the center for language and analytical thinking and also controls motor nerves on the right side of the body. A patient with deficits in these areas most likely has left cerebral involvement. Patients with brainstem or cerebellum involvement will have ataxia and may experience hemiparesis or quadriparesis. The right cerebral hemisphere is involved with visual and spatial awareness.
Which location is the most common site for an embolic stroke?
Middle cerebral artery The most common site for an embolic stroke is the middle cerebral artery. It is not common for an embolic stroke to occur in the common carotid artery, basilar artery, or superior cerebral artery.
Which stroke syndrome has clinical features such as perpetual, spatial, and visual field deficit?
Middle cerebral artery strokes Perpetual, spatial, and visual deficits are key features of middle cerebral artery strokes. Contralateral hemiparesis, hemianopsia, blurred vision, and blindness are key features of internal carotid artery strokes. Contralateral hemiparesis, aphasia, and amnesia are clinical features of anterior cerebral artery strokes. Loss of deep sensation, decreased touch sensation, aphasia, and amnesia are clinical features of posterior cerebral artery strokes.
A patient weighing 165 pounds will begin receiving recombinant tissue plasminogen activator (rtPA) to treat an ischemic stroke. The nurse expects an order to administer how many milligrams of rtPA in the first minute of the infusion? Record your answer using two decimal places. Use a leading zero if applicable. ___ mg
Patients receiving rtPA should receive 0.9 mg/kg over 60 minutes with 10% of that dose given as a bolus over the first minute. This patient weighs 165 lbs, or 75 kg. The total dose for this patient is 67.5 mg (0.9 × 75 = 67.5). Ten percent of that is 6.75 mg. 6.75mg
A patient is having difficulty understanding spoken and written words and is saying made-up words and meaningless speech. What would be the possible reason behind the patient's condition?
Receptive aphasia Receptive aphasia occurs due to injury in Wernicke's area in the temporoparietal area. This leads to the patient having difficulty understanding spoken and written words, creating made-up words, and using meaningless speech. Mixed aphasia is difficulty in expression and reception, which includes difficulty speaking and writing. Global aphasia occurs due to severe damage in the receptive and expressive skills. Expressive aphasia occurs due to difficulty speaking and writing.
The nurse explains to patients at a health camp that there are multiple risk factors responsible for a stroke. Which risk factors does the nurse explain cannot be changed? Select all that apply.
Sickle cell disease and berry aneurysms Sickle cell disease and berry aneurysms are risk factors for developing a stroke that cannot be changed. Patients with sickle cell disease are at risk of stroke at a young age. Berry aneurysms are small, sac-like areas in the artery wall that can rupture at any time, causing bleeding in the brain. Patients with clotting problems or with symptoms of transient ischemic attacks are treated with anticoagulant therapy to prevent the possibility of stroke. Patients with sleep apnea can reduce their weight and use a breathing device at night to prevent stroke.
A patient has experienced a right-hemisphere stroke. What is an important nursing action while caring for this patient?
Stand on the patients left side when talking to increase the visual field Patients with right hemisphere involvement often have an inability to recognize physical impairment and will exhibit neglect of the left visual field. The nurse should stand in the left visual field to encourage the patient to expand the range of vision. Independent ambulation should be discouraged because these patients have poor judgment and may overestimate their abilities. Patients should be encouraged to wash and dress themselves with instructions to care for the affected side first to improve independence.
The emergency room nurse is assessing a patient who presents with a stroke. The nurse finds that the patient shows perseveration, loss of deep sensation, and decreased touch sensation. What should the nurse infer from these symptoms?
The patient had a posterior cerebral artery stroke The posterior cerebral arteries are a pair of blood vessels that supply oxygenated blood to the occipital lobe. Perseveration, loss of deep sensation, and decreased touch sensation are the symptoms of posterior cerebral artery strokes. Perseveration is not a symptom of internal carotid artery, middle cerebral artery, and vertebrobasilar artery strokes. The vertebrobasilar artery supplies blood to the posterior part of the circle of Willis. The middle cerebral artery supplies blood to the cerebrum. The internal carotid artery supplies blood to the brain.
The nurse is caring for a patient one day after the patient suffered a stroke. The patient is fully alert and has weakness of the right side of the body. Which assessment finding indicates an increasing intracranial pressure (ICP)?
The patient is no longer oriented to place The patient with a recent stroke is at risk of increased intracranial pressure (ICP) because of cerebral edema or ongoing intracranial hemorrhage. The first indication of increasing ICP is a change in the level of consciousness. If the patient seems confused and disoriented to place, it indicates an increased ICP, and the primary health care provider should be immediately notified. Urinary incontinence in the patient may indicate focal deficit. Numbness in the right leg may be due to weakness and may be an effect of the stroke, but it does not indicate an increased ICP. A BP of 90/62 mm Hg indicates hypotension. Hypertension is a key feature of increased ICP.
A patient in the emergency department (ED) has slurred speech, confusion, and visual problems, and has been having intermittent episodes of worsening symptoms. The symptoms have a gradual onset. The patient also has a history of hypertension and atherosclerosis. What does the nurse suspect that the patient is probably experiencing?
Thrombotic stroke The patient's symptoms fit the description of a thrombotic stroke. Symptoms of embolic stroke have a sudden onset, unlike this patient's symptoms. The patient would be in a coma if a hemorrhagic stroke had occurred. Intermittent episodes of slurred speech, confusion, and visual problems are transient ischemic attacks, which often are warning signs of an impending ischemic stroke.
Which type of stroke syndrome would most likely cause a coma in a patient?
Vertebrobasilar artery strokes Vertebrobasilar artery strokes occur when blood flow through the vertebrobasilar region is reduced or stopped. This may lead to a coma. The internal carotid artery strokes, middle cerebral artery strokes, and anterior cerebral artery strokes may not lead to coma. The internal carotid artery supplies blood to the brain. The middle cerebral artery supplies blood to the cerebrum. The anterior cerebral artery supplies oxygenated blood to most of the portions of the frontal lobes and superior medial parietal lobes
