NUR2239 Ch67

The provider diagnoses the patient as having had an ischemic stroke. The etiology of an ischemic stroke would include which of the following?

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

What is a hemorrhagic stroke?

caused by bleeding into the brain, ventricles, or subarachnoid space. Represents 15% of strokes.

A patient is in the acute phase of an ischemic stroke. How long does the nurse know that this phase may last?

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.

What is an ischemic stroke?

Stroke, or cerebrovascular accident, is the third leading cause of death in the US and the leading cause of long-term disability Majority of strokes are ischemic, resulting from decreased blood supply to a part of the brain due to a thrombus or embolus.

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

The day the patient has the stroke Although rehabilitation begins on the day the patient has the stroke, the process is intensified during convalescence and requires a coordinated team effort.

When communicating with a client who has sensory (receptive) aphasia, the nurse should:

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.

Which is the most common motor dysfunction seen in clients diagnosed with stroke?

Hemiplegia The most common motor dysfunction is hemiplegia (paralysis of one side of the body) caused by a lesion on the opposite side of the brain. Ataxia is impaired ability to coordinate movement. Diplopia is double vision. Hemiparesis is weakness of one side of the body.

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

Keeping the client in one position to decrease bleeding 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.

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.

Poor abstract reasoning Decreased attention span Short- and long-term memory loss Cognitive deficits associated with stroke include short- and long-term memory loss, decreased attention span, and poor abstract reasoning. Expressive aphasia is a verbal deficit, not a cognitive deficit. Paresthesias are sensory deficits, not cognitive deficits.

A client is prescribed sumatriptan for the treatment of migraine headache. Which client statement would indicate a need for additional teaching from the nurse?

"I use this to prevent migraines." Sumatriptan is a serotonin receptor agonist that stimulates serotonin receptors in the brain and causes vasoconstriction of the cerebral arteries and reduce/eliminate headaches and other symptoms associated with migraines. Sumatriptan is used during an attack and is not indicated for preventative migraine therapy.

A client who complains of recurring headaches, accompanied by increased irritability, photophobia, and fatigue is asked to track the headache symptoms and occurrence on a calendar log. Which is the best nursing rationale for this action?

Migraines often coincide with menstrual cycle. Changes in reproductive hormones as found during menstrual cycle can be a trigger for migraine headaches and may assist in the management of the symptoms. Cluster headaches can cause severe pain but is not the reason for tracking. Tension headaches can be managed but is not associated with a monthly calendar. Headaches are common but not the reason for tracking.

A transcranial Doppler ultrasonography detects cerebral vasospasms in a client experiencing lethargy 8 days following a subarachnoid hemorrhage. The nurse anticipates which therapeutic intervention?

Nimodipine PO Medication may be effective in the treatment of vasospasm. Based on one theory, that vasospasm is caused by an increased influx of calcium into the cell, medication therapy may be used to block or antagonize this action and prevent or reverse the action of vasospasm if already present. The most frequently used calcium channel blocker is nimodipine. The other interventions and medications are not used to treat vasospasms.

Clinical manifestations of Ischemic Stroke

Varies depending on the part of the brain affected, but common manifestations are numbness or weakness of the face or extremities (usually unilateral), confusion, cognitive deficits, expressive or receptive aphasia, visual disturbances, ataxia, dizziness, and headache

Modifiable risk factors

hypertension, atrial fibrillation, hyperlipidemia, diabetes, smoking, carotid stenosis, obesity, alcoholism

The nurse plays a critical role in the initial work-up of a patient with acute stroke symptoms. An immediate decision is to determine if the stroke is ischemic or hemorrhagic. Although there is overlap in some motor, sensory, and cognitive changes, hemorrhagic strokes can be identified by some specific signs. Which of the following signs are consistent with a hemorrhagic stroke? Select all that apply.

Vomiting Sudden, severe headache Seizures These three signs are usually diagnostic of a hemorrhagic stroke. The other signs can occur with both hemorrhagic and ischemic stroke.

Risk factors

age, gender, hypertension, use of alcohol or certain drugs, and presence of arteriovenous malformations, intracranial neoplasms, or intracranial aneurysms

A nurse is instructing the spouse of a client who suffered a stroke about the use of eating devices the client will be using. During the teaching, the spouse starts to cry and states, "One minute he is laughing, and the next he's crying; I just don't understand what's wrong with him." Which statement is the best response by the nurse?

"Emotional lability is common after a stroke, and it usually improves with time." This is the most therapeutic and informative response. Often, most relatives of clients with stroke handle the physical changes better than the emotional aspects of care. The family should be prepared to expect occasional episodes of emotional lability. The client may laugh or cry easily and may be irritable and demanding or depressed and confused. The nurse can explain to the family that the client's laughter does not necessarily connote happiness, nor does crying reflect sadness, and that emotional lability usually improves with time. The remaining responses are nontherapeutic and do not address the spouse's concerns.

A client recently experienced a stroke with accompanying left-sided paralysis. His family voices concerns about how to best interact with him. They report the client doesn't seem aware of their presence when they approach him on his left side. What advice should the nurse give the family?

"The client is unaware of his left side. You should approach him on the right side." The client is experiencing unilateral neglect and is unaware of his left side. The nurse should advise the family to approach him on his unaffected (right) side. Approaching the client on the affected side would be counterproductive. It's too premature to make the determination whether this condition will be permanent.

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

Assist the client with meals. Test the gag reflex before offering food or fluids. Allow ample time to eat. Interventions for dysphagia include placing food on the unaffected side of the mouth, allowing ample time to eat, assisting the client with meals, and testing the client's gag reflex before offering food or fluids.

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

Atrial fibrillation Atrial fibrillation is the most frequently diagnosed arrhythmia in the United States. If left untreated, it can lead to an ischemic stroke. Cerebral hemorrhage, arteriovenous malformation, and cerebral hemorrhage can lead to a hemorrhagic stroke. Cerebral aneurysm, arteriovenous malformations, and ruptured cerebral arteries can lead to hemorrhagic stroke.

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

Auditory agnosia 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 motor neurons may cause hemiparesis, hemiplegia, and a change in reflexes.

Eligibility Criteria for Tissue Plasminogen Activator Administration

Age ≥18 years Clinical diagnosis of ischemic stroke Time of onset of stroke known and is less than 3 hours before treatment Systolic blood pressure ≤185 mm Hg; diastolic ≤110 mm Hg No minor stroke or rapidly resolving stroke No seizure at onset of stroke Prothrombin time ≤15 seconds or international normalized ratio ≤1.7 (if taking an anticoagulant, the same guidance is used) Not received heparin during the past 48 hours with elevated partial thromboplastin time Platelet count ≥100,000/mm3 Glucose >50 mg/dL No prior intracranial hemorrhage, neoplasm, arteriovenous malformation, or aneurysm No major surgical procedures or serious trauma within 14 days No stroke, serious head injury, or intracranial surgery within 3 months No gastrointestinal or urinary bleeding within 21 days No pregnancy Some of these are relative contraindications (the provider administering the medication needs to weigh the risks and benefits of the therapy). There are more stringent criteria if t-PA is considered for those patients in the 3.0- to 4.5-hour time window.

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

Apraxia Verbal apraxia refers to difficulty forming and organizing intelligible words although the musculature is intact. Agnosia is a 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.

A nurse is caring for a client who has returned to his room after a carotid endarterectomy. Which action should the nurse take first?

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.

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

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.

A client is following up after a visit to the emergency department where testing indicated that the client had suffered a transient ischemic attack. What lifestyle changes would the nurse include in teaching to prevent further reoccurrence? Select all that apply.

Blood pressure control Weight loss Smoking cessation Primary prevention of ischemic stroke remains the best approach. A healthy lifestyle including not smoking, engaging in physical activity (at least 40 minutes a day, 3 to 4 days a week), maintaining a healthy weight, and following a healthy diet (including modest alcohol consumption) can reduce the risk of having a stroke. Specific diets that have decreased risk of stroke include the Dietary Approaches to Stop Hypertension (DASH) diet (high in fruits and vegetables, moderate in low-fat dairy products, and low in animal protein), the Mediterranean diet (supplemented with nuts), and overall diets that are rich in fruits and vegetables. Research findings suggest that low-dose aspirin may lower the risk of a first stroke for those who are at risk.

A 76-year-old client is brought to the clinic by his daughter. The daughter states that her father has had two transient ischemic attacks (TIAs) in the past week. The physician orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option does the nurse expect the physician to offer this client to increase blood flow to the brain?

Carotid endarterectomy If narrowing of the carotid artery by atherosclerotic plaques is the cause of the TIAs, a carotid endarterectomy (surgical removal of atherosclerotic plaque) is a treatment option. A balloon angioplasty, a procedure similar to a percutaneous transluminal coronary artery angioplasty, is performed to dilate the carotid artery and increase blood flow to the brain. Options A, B, and C are not surgical options to increase blood flow through the carotid artery to the brain.

After the patient has received tPA, the nurse knows to check vital signs every 30 minutes for 6 hours. Which of the following readings would require calling the provider?

Diastolic pressure of 110 mm Hg A diastolic pressure reading of over 105 mm Hg warrants notifying the health care provider. The other choices are within normal range.

A patient suffering a stroke is having a difficult time swallowing. What would the nurse document this finding as?

Dysphagia Stroke can result in dysphagia (difficulty swallowing) due to impaired function of the mouth, tongue, palate, larynx, pharynx, or upper esophagus. Patients must be observed for paroxysms of coughing, food dribbling out of or pooling in one side of the mouth, food retained for long periods in the mouth, or nasal regurgitation when swallowing liquids. Swallowing difficulties place the patient at risk for aspiration, pneumonia, dehydration, and malnutrition.

After a stroke, a client is admitted to the facility. The client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g. Which nursing intervention is a priority for this client?

Elevating the head of the bed to 30 degrees Because the client's gag reflex is absent, elevating the head of the bed to 30 degrees helps minimize the client's risk of aspiration. Checking the stools, performing ROM exercises, and keeping the skin clean and dry are important, but preventing aspiration through positioning is the priority.

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

Establishing eye contact The following strategies should be used by the nurse to encourage communication with a client with aphasia: face the client and establish eye contact, speak in your usual manner and tone, use short phrases, and pause between phrases to allow the client time to understand what is being said; limit conversation to practical and concrete matters; use gestures, pictures, objects, and writing; and as the client 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 client or make it difficult to sort out the message being spoken.

Aneurysm rebleeding occurs most frequently during which time frame after the initial hemorrhage?

First 2 to 12 hours Aneurysm rebleeding occurs most frequently during the first 2 to 12 hours after the initial hemorrhage and is considered a major complication.

A client undergoes cerebral angiography for evaluation of a subarachnoid hemorrhage. Which findings indicate spasm or occlusion of a cerebral vessel by a clot?

Hemiplegia, seizures, and decreased level of consciousness Spasm or occlusion of a cerebral vessel by a clot causes signs and symptoms similar to those of a stroke: hemiplegia, seizures, decreased level of consciousness, aphasia, hemiparesis, and increased focal symptoms. Nausea, vomiting, and profuse sweating suggest a delayed reaction to the contrast medium used in cerebral angiography. Difficulty breathing or swallowing may signal a hematoma in the neck. Tachycardia, tachypnea, and hypotension suggest internal hemorrhage.

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

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 healthcare provider may use dexamethasone (Decadron) to decrease cerebral edema and pressure, methyldopa (Aldomet) to reduce blood pressure, and phenytoin (Dilantin) to prevent seizures.

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

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

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

Impaired Swallowing Impaired Swallowing was evident on the video fluoroscopy. Risk for Aspiration, Altered Nutrition, and Fluid Volume Deficit can occur but are not the primary diagnosis at this point in time.

A client is receiving an IV infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To confirm that this drug is producing its therapeutic effect, the nurse should consider which finding most significant?

Increased urine output 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 practitioner provides health teaching to a patient who has difficulty managing hypertension. This patient is at an increased risk of which type of stroke?

Intracerebral hemorrhage About 80% of hemorrhagic strokes are intracerebral, and they are caused primarily by uncontrolled hypertension.

Which is a contraindication for the administration of tissue plasminogen activator (t-PA)?

Intracranial hemorrhage Intracranial hemorrhage, neoplasm, and aneurysm are contraindications for t-PA. Clinical diagnosis of ischemic stroke, age 18 years or older, and a systolic blood pressure less than or equal to 185 mm Hg are eligibility criteria.

Which are contraindications for the administration of tissue plasminogen activator (t-PA)? Select all that apply.

Intracranial hemorrhage Major abdominal surgery within 10 days Intracranial hemorrhage, neoplasm, aneurysm, and major surgical procedures within 14 days are contraindications to t-PA. Clinical diagnosis of ischemic stroke, being 18 years of age or older, and a systolic BP less than or equal to 185 mm Hg are eligibility criteria.

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

Lack of deep tendon reflexes 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.

A client has experienced an ischemic stroke that has damaged the frontal lobe of his brain. Which of the following deficits does the nurse expect to observe during assessment?

Limited attention span and forgetfulness Damage to the frontal lobe may impair learning capacity, memory, or other higher cortical intellectual functions. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and a lack of motivation. Damage to the motor neurons may cause hemiparesis, hemiplegia, and a change in reflexes. Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia.

A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem?

Lioresal (Baclofen) 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).

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

Maintaining a patent airway Maintaining the airway is the most important nursing intervention. Immediate complications of a hemorrhagic stroke include cerebral hypoxia, decreased cerebral blood flow, and extension of the area of injury. Providing adequate oxygenation of blood to the brain minimizes cerebral hypoxia. Brain function depends on delivery of oxygen to the tissues. Administering supplemental oxygen and maintaining hemoglobin and hematocrit at acceptable levels will assist in maintaining tissue oxygenation. All other interventions are appropriate, but the airway takes priority. The head of the bed should be elevated to 30 degrees, monitoring the client because of the risk for seizures, and stool softeners are recommended to prevent constipation and straining, but these are not the most important interventions.

A client is admitted for evaluation of cerebral aneurysm. Which assessment finding is of greatest importance in prioritizing nursing care to this client?

Nausea Nausea needs to be controlled to prevent vomiting, which can greatly increase the intracranial pressure and subsequently rupture the aneurysm. Complaint of headache for past month is significant and probably attributes to the evaluation at hand. Having no bowel movement since yesterday is not significant; although, every effort should be made to prevent constipation. Frequent voiding is expected especially with the use of osmotic diuretics.

A patient is brought to the emergency department with a possible stroke. What initial diagnostic test for a stroke, usually performed in the emergency department, would the nurse prepare the patient for?

Noncontrast computed tomogram The initial diagnostic test for a stroke is usually a noncontrast computed tomography (CT) scan. This should be performed within 25 minutes or less from the time the patient presents to the emergency department (ED) to determine if the event is ischemic or hemorrhagic (the category of stroke determines treatment).

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

Noncontrast computed tomography (CT) An initial head CT scan will determine whether or not the patient is experiencing a hemorrhagic stroke. An ischemic infarction will not be readily visible on initial CT scan if it is performed within the first few hours after symptoms onset; however, evidence of bleeding will almost always be visible.

The nurse is caring for a client diagnosed with a subarachnoid hemorrhage resulting from a leaking aneurysm. The client is awaiting surgery. Which nursing interventions would be appropriate for the nurse to implement? Select all that apply.

Provide a dimly lit environment. Elevate the head of bed 30 degrees. Administer docusate per order. Cerebral aneurysm precautions are implemented for the patient with a diagnosis of aneurysm to provide a nonstimulating environment, prevent increases in intracranial pressure (ICP), and prevent further bleeding. The patient is placed on immediate and absolute bed rest in a quiet, nonstressful environment, because activity, pain, and anxiety elevate blood pressure, which increases the risk for bleeding. Visitors, except for family, are restricted. Dim lighting is helpful because photophobia (visual intolerance of light) is common. The head of the bed is elevated 15 to 30 degrees to promote venous drainage and decrease ICP. No enemas are permitted, but stool softeners (Colace) and mild laxatives are prescribed. Both prevent constipation, which would cause an increase in ICP, as would enemas.

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

Psychosis, disorientation, delirium, insomnia, and hallucinations Advances in technology have led to the introduction of interventional neuroradiology for the treatment of aneurysms. Endovascular techniques may be used in selected clients to occlude the blood flow from the artery that feeds the aneurysm with coils or other techniques to occlude the aneurysm itself. Postoperative complications are rare but can occur. Potential complications include psychological symptoms such as disorientation, amnesia, and Korsakoff syndrome (disorder characterized by psychosis, disorientation, delirium, insomnia, hallucinations, and personality changes). Creutzfeldt-Jakob disease results in severe dementia and myoclonus. The three cardinal signs of Parkinson disease are tremor, rigidity, and bradykinesia. Huntington disease results in progressive involuntary choreiform (dancelike) movements and dementia.

Which set of symptoms characterize Korsakoff syndrome?

Psychosis, disorientation, delirium, insomnia, and hallucinations Korsakoff syndrome is a personality disorder characterized by psychosis, disorientation, delirium, insomnia, and hallucinations. Creutzfeldt-Jacob disease results in severe dementia and myoclonus. The three cardinal signs of Parkinson disease are tremor, rigidity, and bradykinesia. Huntington disease results in progressive involuntary choreiform (dancelike) movements and dementia.

A nurse is caring for a client with a cerebral aneurysm. Which nursing interventions would be most useful to the nurse to avoid bleeding in the brain? Select all that apply.

Report changes in neurologic status as soon as a worsening trend is identified. Maintain the head of the bed at 30 degrees. Avoid any activities that cause a Valsalva maneuver. Cerebral aneurysm precautions are implemented for the patient with a diagnosis of aneurysm to provide a nonstimulating environment, prevent increases in intracranial pressure, and prevent further bleeding. The patient is placed on bed rest in a quiet, nonstressful environment, because activity, pain, and anxiety are thought to elevate the blood pressure, which may increase the risk for bleeding. The head of the bed is elevated 30 degrees to promote venous drainage and decrease intracranial pressure. Any activity that suddenly increases the blood pressure or obstructs venous return is avoided. This includes the Valsalva maneuver, straining, forceful sneezing, pushing oneself up in bed and acute flexion or rotation of the head and neck (which compromises the jugular veins). Stool softeners and mild laxatives are prescribed to prevent constipation, which can cause an increase in intracranial pressure. Dim lighting is helpful for photophobia. Increasing fluid volume does not affect brain bleeding.

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

Restrict fluids before surgery. Before surgery, the nurse should restrict fluids to avoid intraoperative complications, reduce cerebral edema, and prevent postoperative vomiting. The nurse administers prescribed medications such as an anticonvulsant phenytoin, like Dilantin, to reduce the risk of seizures before and after surgery, an osmotic diuretic, and corticosteroids. Preoperative sedation is omitted.

The nurse is providing information about strokes to a community group. Which of the following would the nurse identify as the primary initial symptoms of an ischemic stroke?

Weakness on one side of the body and difficulty with speech 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. Foot drop and external hip rotation are things that can occur if a stroke victim is not turned or positioned correctly.

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

Right-sided paralysis. A left hemispheric stroke will cause right-sided weakness or paralysis. Because upper motor neurons decussate, a disturbance on one side of the body can cause damage on the opposite side of the brain. Refer to Box 47-2 in the text.

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

Severe headache and early change in level of consciousness The 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. Foot drop and external hip rotation can occur if a stroke victim is not turned or positioned correctly.

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

Smoking Modifiable risk factors for transient ischemic attack (TIA) and ischemic stroke include hypertension, type 1 diabetes, cardiac disease, smoking, and chronic alcoholism. Advanced age, gender, and race are nonmodifiable risk factors for stroke.

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

Spatial-perceptual deficits Clients with right hemispheric stroke exhibit partial perceptual deficits, left visual field deficit, and paralysis with weakness on the left side of the body. Left hemispheric damage causes aphasia, slow, cautious behavior, and altered intellectual ability.

A client reports light-headedness, speech disturbance, and left-sided weakness lasting for several hours. The neurologist diagnosed a transient ischemic attack, which caused the client great concern. What would the nurse include during client education?

When symptoms cease, the client will return to presymptomatic state. Impaired blood circulation can be caused by arteriosclerosis, cardiac disease, or diabetes. A TIA is a sudden, brief episode of neurologic impairment. Symptoms may disappear within 1 hour; some continue for as long as 1 day. One third of people who experience a TIA subsequently develop a stroke.

Nonmodifiable risk factors

age, gender, race

A client diagnosed with a stroke is ordered to receive warfarin. Later, the nurse learns that the warfarin is contraindicated and the order is canceled. The nurse knows that the best alternative medication to give is

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

A nurse is reading a journal article about stroke and the underlying causes associated with this condition. The nurse demonstrates understanding of the information when identifying which subtype of stroke as being due to atrial fibrillation?

cardio embolic Ischemic strokes are further divided into five subtypes, according to a mechanism-based classification system: large-artery thrombotic strokes (representing 20% of ischemic strokes); small, penetrating artery thrombotic strokes (25%); cardio embolic strokes (20%); cryptogenic strokes (strokes that cannot be attributed to any specific cause) (30%); and "other" (5%). Large-artery thrombotic strokes are caused by atherosclerotic plaques in the large blood vessels of the brain. Thrombus formation and occlusion can occur at the site of the atherosclerosis and result in ischemia and infarction (tissue death). Small, penetrating artery thrombotic strokes that affect one or more vessels and cause reduced blood flow are the most common type of ischemic stroke, typically caused by longstanding hypertension, hyperlipidemia, or diabetes. Cardio embolic strokes are associated with cardiac dysrhythmias, such as atrial fibrillation, but can also be associated with valvular heart disease or left ventricular thrombus. The last two classifications of ischemic strokes are cryptogenic strokes, which have no identified cause, and strokes from other causes, such as illicit drug use (cocaine), coagulopathies, migraine, or spontaneous dissection of the carotid or vertebral arteries.

A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the health care provider in the emergency department. Which is the origin of the client's symptoms?

impaired cerebral circulation TIAs involve the same mechanism as in the ischemic cascade, but symptoms are transient (< 24 hours) and there is no evidence of cerebral tissue infarction. The ischemic cascade begins when cerebral blood flow decreases to less than 25 mL/100 g/min and neurons are no longer able to maintain aerobic respiration. Thus, a TIA results directly from impaired blood circulation in the brain. Atherosclerosis, cardiac disease, hypertension, or diabetes can be risk factors for a TIA but do not cause it.

A client has a 12-year history of migraine headaches and is frustrated over how these headaches impact lifestyle. The nurse discusses the potential triggers of the client's migraines. Which is not a potential trigger to migraines?

seasonal changes Researchers believe the contributing cofactors for the cause of migraines are from changes in serotonin receptors that promote dilation of cerebral blood vessels and pain intensification from neurochemicals released from the trigeminal nerve. It has been suggested that fluctuations in reproductive hormones, chemicals in certain foods, and medications can trigger migraines.

Clinical manifestations of hemorrhagic stroke

similar to ischemic stroke. in addition to numbness or weakness of the face or extremities (unilateral usually), confusion, cognitive deficits, expressive or receptive aphasia, visual disturbances, ataxia, and dizziness, the patient may experience a sudden or severe headache, vomiting and focal seizures