Nurs 4 - Mod 10 - Stroke EAQ"s

A registered nurse is teaching a student nurse about the management of increased intracranial pressure in a patient who sustained a stroke. Which statement made by the student nurse indicates the need for further teaching? 1 "The patient should be placed in a supine position." 2 "The patient's head and neck should be in alignment." 3 "The patient's bowel function status should be maintained." 4 "The patient's temperature should be maintained between 96.8° F to 98.6° F."

1 - "The patient should be placed in a supine position." If the nurse suspects increased intercranial pressure, the patient's head should be elevated and the head and neck should be aligned to improve venous drainage. Constipation increases intracranial pressure; therefore, treating constipation is important. The patient's body temperature should be maintained at or near normal (96.8° F to 98.6° F) to avoid hyperthermia.

During the acute stage of a stroke, it is important for the nurse to include which intervention for a patient experiencing aphasia? 1 Ask simple yes and no questions. 2 Limit verbal communication to reduce frustration. 3 If the patient is unable to answer a question, divert eye contact to reduce embarrassment. 4 If patient does not answer immediately, ask the patient if he or she understands or needs you to repeat the information.

1 - Ask simple yes and no questions. Asking questions that can be answered simply supports communication in the acute phase of a stroke. Verbal communication should not be limited but should be frequent and meaningful. Diverting eye contact is incorrect because it will increase embarrassment instead of reducing it. It is important to give the patient time to answer a question. Asking a second question before the patient has had time to answer the first one will increase frustration and decrease communication.

Which medical condition places a patient at a higher risk for an embolic stroke? 1 Atrial fibrillation 2 Atherosclerosis 3 Cancer of the brain 4 Anticoagulant therapy

1 - Atrial fibrillation Atrial fibrillation can cause a significant number of embolic strokes. Anticoagulant therapy can cause hemorrhage strokes. Cancer of the brain is related to a mass in the cranium, not the blood vessels. Atherosclerosis causes narrowing of the blood vessels and reduces cranial blood flow.

The nurse is reviewing a patient's chart for factors that may have predisposed the patient to a recent stroke. Which factors placed this patient at risk for the stroke and should be included in the nurse's teaching plan? Select all that apply. 1 Atrial fibrillation 2 Walks once a week 3 Quit smoking in 1984 4 History of breast cancer 5 History of urinary tract infections 6 Drinks three glass of red wine daily

1 - Atrial fibrillation 2 - Walks once a week 6 - Drinks three glass of red wine daily Atrial fibrillation is responsible for 25% of all strokes. The American Stroke Association recommends 40 minutes of exercise three to four times a week. Drinking more than one glass of wine daily increases the risk of stroke. After five to 10 years without tobacco use, the risk of stroke from smoking is similar to that of nonsmokers. Breast cancer and urinary tract infections are not considered risks for stroke.

The nurse assesses atrial fibrillation on the cardiac monitor. What type of stroke does the nurse anticipate for the patient to experience, if left without treatment? 1 Embolic stroke 2 Thrombotic stroke 3 Intracerebral hemorrhage 4 Subarachnoid hemorrhage

1 - Embolic stroke Heart conditions such as atrial fibrillation and infective endocarditis can cause embolic stroke. A thrombotic stroke has clinical manifestations of decreased level of consciousness in the first 24 hours. Intracerebral hemorrhage has clinical manifestations such as decreased level of consciousness and hypertension. Clinical manifestations such as stiff neck and cranial nerve deficits indicate a subarachnoid hemorrhage.

A nurse is caring for stroke patients. What should the nurse include in the bladder retraining program of a stroke-affected patient? Select all that apply. 1 Encourage adequate fluid intake. 2 Observe for signs of restlessness. 3 Assess bladder distention by palpation. 4 Change the urinary catheters periodically. 5 Place the bedpan near the bed at all times.

1 - Encourage adequate fluid intake. 2 - Observe for signs of restlessness. 3 - Assess bladder distention by palpation. In the acute stage of stroke, the primary urinary problem is poor bladder control, resulting in incontinence. Hence, steps should be taken to promote normal bladder control. Adequate fluid intake should be encouraged to promote urine formation and bladder activity. Signs of restlessness may indicate the need for urination and hence should be closely observed. The bladder may be palpated regularly to assess urine retention. Use of indwelling catheters should be avoided because of the risk of infection. The usual position for urinating should be encouraged; the patient may not make an effort to do so if a bedpan is placed near the bed at all times.

A nurse assesses the blood pressure (BP) of a patient who had a stroke and finds it to be 166/96 mm Hg. What is the priority action by the nurse? Select all that apply. 1 Ensure adequate fluid intake. 2 Start oral antihypertensive drugs. 3 Consider this as a protective response. 4 Start intravenous antihypertensive drugs. 5 Call the health care provider immediately.

1 - Ensure adequate fluid intake. 3 - Consider this as a protective response. Elevated BP is common immediately after a stroke. It is important to provide adequate fluid intake during acute care to maintain hydration. Elevation of BP is a protective response to maintain cerebral perfusion. Therefore it is not necessary to call the health care provider. Antihypertensives should be started only if there is a marked increase in BP (systolic greater than 220 mm Hg or diastolic greater than 120 mm Hg).

What should be included in the nursing plan for prevention of skin breakdown in a stroke patient? Select all that apply. 1 Good skin hygiene 2 Massaging the damaged area 3 Applying emollients to dry skin 4 Minimizing the frequency of position changes 5 Administering back rubs with alcohol for a cooling effect

1 - Good skin hygiene 3 - Applying emollients to dry skin The skin of a patient with stroke is particularly susceptible to breakdown related to loss of sensation, decreased circulation, and immobility. Therefore the nursing prevention plan for skin breakdown should include pressure relief interventions such as position changes, application of emollients to dry skin, good skin hygiene, and early mobility. Massage to the damaged area may cause additional damage and should be avoided. Back rubs can be very relaxing, but should be done with lotion or oil, not alcohol, which is very drying to the skin.

Which are primary methods of preventing a stroke? Select all that apply. 1 Healthy diet 2 Regular exercise 3 Stroke rehabilitation 4 Breast self-examination 5 Knowing the signs of stroke 6 Management of blood pressure

1 - Healthy diet 2 - Regular exercise 6 - Management of blood pressure Primary stroke prevention includes a healthy diet, regular exercise, and management of blood pressure. Secondary prevention includes knowing the signs of stroke. Breast self-examination is secondary prevention for breast cancer, not stroke. Stroke rehabilitation is tertiary prevention to prevent disability after a stroke.

A computed tomography (CT) scan of the head of a patient reveals that the patient has experienced a hemorrhagic stroke. What is the priority nursing intervention in the emergency department? 1 Maintenance of the patient's airway 2 Positioning to promote cerebral perfusion 3 Control of fluid and electrolyte imbalances 4 Administration of tissue plasminogen activator (tPA)

1 - Maintenance of the patient's airway Maintenance of a patent airway is the priority in the acute care of a patient with a hemorrhagic stroke. It supersedes the importance of fluid and electrolyte imbalance and positioning. tPA is contraindicated in hemorrhagic stroke.

The nurse is planning care for a group of patients on a stroke unit. What tasks can the nurse delegate to unlicensed assistive personnel? Select all that apply. 1 Measuring and recording oral intake and urine/bowel output 2 Screening patients for tissue plasminogen activator therapy 3 Assessing neurologic status using the Glasgow Coma Scale 4 Providing oral and lip care at least every 2 hours and as needed 5 Placing equipment needed for seizure precautions in the patient's room 6 Assisting with positioning the patient and turning the patient at least every two hours

1 - Measuring and recording oral intake and urine/bowel output 4 - Providing oral and lip care at least every 2 hours and as needed 5 - Placing equipment needed for seizure precautions in the patient's room 6 - Assisting with positioning the patient and turning the patient at least every two hours A registered nurse can delegate unlicensed assistive personnel to place equipment needed for seizure precautions in the patient's room, to assist with positioning the patient and turning the patient at least every two hours, to provide oral and lip care at least every 2 hours and as needed, and to measure and record oral intake and urine/bowel output. Only a registered nurse can screen patients for tissue plasminogen activator therapy and assess neurologic status using the Glasgow Coma Scale.

A patient is admitted to the hospital with a stroke. Which interventions should be included in the acute care of a stroke patient? Select all that apply. 1 Monitor urine output. 2 Monitor the blood sugar level. 3 Ensure adequate fluid intake. 4 Start 5% dextrose intravenously. 5 Use medications to lower the blood pressure (BP).

1 - Monitor urine output. 2 - Monitor the blood sugar level. 3 - Ensure adequate fluid intake. Hypoglycemia may be associated with further brain damage; hence, it is important to check blood sugar levels. Adequate fluid intake is important to avoid dehydration. Urine output should be monitored to make sure the patient does not become dehydrated. Intravenous solutions such as 5% dextrose are hypotonic and may further increase cerebral edema and intracranial pressure. Elevated BP is a protective response to maintain cerebral perfusion, and antihypertensives should be started only if the BP is markedly increased.

Place the following collaborative interventions in order of priority for a patient presenting with acute stroke symptoms. 1. Establish intravenous (IV) access 2. Ensure patent airway 3. Anticipate thrombolytic therapy 4. Perform pulse oximetry 5. Provide supplemental oxygen as indicated 6. Obtain computed tomography (CT) scan

1. - Ensure patent airway 2. - Perform pulse oximetry 3. - Provide supplemental oxygen as indicated 4. - Establish intravenous (IV) access 5. - Obtain computed tomography (CT) scan 6. - Anticipate thrombolytic therapy Using the airway, breathing, circulation (ABC) approach, the first intervention would be to ensure a patent airway. A baseline pulse oximetry reading should then be obtained and supplemental oxygen provided to keep oxygen saturation above 95%. An IV access then will be placed, because this will provide a lifeline for emergency medications as prescribed. Prompt diagnosis of the stroke is imperative, so the patient should be prepared for and transported to radiology for a CT of the brain. Once CT findings are reported, consideration for thrombolytic therapy for nonhemorrhagic strokes will be done next.

A patient diagnosed with atrial fibrillation has been put on the oral anticoagulant warfarin. What instructions should the nurse give the patient? Select all that apply. 1 "Stop the drug if you feel all right." 2 "The drug requires close monitoring." 3 "Lower the dose of the drug if you feel all right." 4 "Do not take the drug if you are not comfortable." 5 "Do not stop the drug without informing the doctor."

2 - "The drug requires close monitoring." 5 - "Do not stop the drug without informing the doctor." Warfarin requires close monitoring because of its side effects. The dosage is also adjusted and is different for every patient. The patient should not discontinue the drug for any reason or decrease the dosage without informing the doctor.

The brain requires a continuous supply of blood and oxygen. If it is interrupted, how quickly does cellular death occur? 1 2 minutes 2 5 minutes 3 30 minutes 4 30 seconds

2 - 5 minutes Cellular death occurs within 5 minutes of a disruption in blood flow. Neurologic metabolism is altered in 30 seconds when the blood flow to the brain is interrupted. Metabolism stops in 2 minutes. Cellular death occurs much more quickly than in 30 minutes.

A nurse is screening patients to determine if administering tissue plasminogen activator (tPA) for fibrinolytic therapy is an appropriate intervention. Which patients may be administered tPA safely? Select all that apply. 1 A 30-year-old with hemophilia A 2 A 70-year-old with blood sugar levels of 110 mg/dL 3 A 40-year-old with history of head injury six months ago 4 A 25-year-old with history of cholecystectomy two years previously 5 A 35-year-old with a computed tomography (CT) scan showing hemorrhagic stroke

2 - A 70-year-old with blood sugar levels of 110 mg/dL 3 - A 40-year-old with history of head injury six months ago 4 - A 25-year-old with history of cholecystectomy two years previously In ischemic stroke, recombinant tPA is used to produce localized fibrinolysis by binding to the fibrin thrombi. Patients are screened before tPA can be given. Screening includes a noncontrast CT or magnetic resonance imaging to rule out hemorrhagic stroke; a blood test for glucose level and coagulation disorders; and screening for recent history of gastrointestinal bleeding, stroke or head trauma within the past three months, or major surgery within 14 days. The patient who underwent major surgery two years ago can be given tPA because there is no risk of bleeding. The patient with a blood sugar level of 110 mg/dL can be administered tPA safely because the blood sugar level is normal. The patient with a history of head injury six months previously can also be administered tPA because there is no risk of bleeding. However, the patient with a CT scan showing hemorrhagic stroke or the patient with hemophilia have a very high risk of bleeding due to the fibrinolytic action of tPA; therefore, it should not be administered to these patients.

The nurse finds that the patient is unable to recognize familiar objects after a stroke. What term does the nurse chart in the patient's medical record? 1 Alexia 2 Agnosia 3 Aphasia 4 Agraphia

2 - Agnosia Agnosia is the inability to recognize familiar objects. Aphasia is difficulty in speaking or understanding speech. Alexia is difficulty reading. Agraphia is difficulty writing.

A patient has left-sided hemiplegia following an ischemic stroke that was experienced four days earlier. How should the nurse best promote the health of the patient's integumentary system? 1 Position the patient on the weak side the majority of the time. 2 Alternate the patient's positioning between supine and side-lying. 3 Avoid the use of pillows to promote independence in positioning. 4 Establish a schedule for the massage of areas where skin breakdown emerges.

2 - Alternate the patient's positioning between supine and side-lying. A position change schedule should be established for stroke patients. An example is side-back-side, with a maximum duration of two hours for any position. The patient should be positioned on the weak or paralyzed side for only 30 minutes. Pillows may be used to facilitate positioning. Areas of skin breakdown should never be massaged.

A patient sustained an ischemic stroke and is given an intravenous (IV) solution with glucose and water. What is the expected change that the nurse monitors in the patient? 1 A decrease in urine output 2 An increase in cerebral edema 3 A decrease in intracranial pressure 4 A maintained balance of fluids and electrolytes

2 - An increase in cerebral edema IV solutions with glucose and water are hypotonic. Therefore they will increase cerebral edema. Because IV solutions with glucose and water increase cerebral edema, changes will also include an increase in urine output and intracranial pressure in the patient. IV solutions with glucose and water will also alter the fluid and electrolyte balance and must be controlled carefully.

A patient is suspected of having a subarachnoid hemorrhage. For which diagnostic test will the nurse prepare the patient, as the most reliable diagnostic study to identify the source of subarachnoid hemorrhage? 1 Cardiac imaging 2 Cerebral angiography 3 Magnetic resonance angiography 4 Computed tomography angiography

2 - Cerebral angiography Cerebral angiography is the most reliable diagnostic study to identify the source of subarachnoid hemorrhage. This test helps identify cervical and cerebrovascular occlusions. Cardiac imaging, magnetic resonance angiography, and computed tomography angiography are not as definitive for identifying the source of subarachnoid hemorrhage.

Which aspects of the medical history of a female patient who has had a stroke could be associated with the event? Select all that apply. 1 Chronic low back pain. 2 Current use of high-dose oral contraceptives. 3 History of long-standing hair loss. 4 History of migraine headaches with aura. 5 Past employment involving exposure to chemical dyes.

2 - Current use of high-dose oral contraceptives. 4 - History of migraine headaches with aura. Oral contraceptive pills with high levels of progestin and estrogen increase a woman's chance of experiencing stroke. People with migraine are at an increased risk of stroke, although the mechanism for the increased risk in women with migraines remains unknown. Low back pain, hair loss, and past employment working with dyes do not increase the risk of stroke.

A nurse is measuring the blood pressure of a hypertensive obese patient who has been admitted to the hospital for increased blood glucose levels. While they are speaking, the nurse notes that the patient has suddenly started mumbling and is unable to articulate words. What is the nurse's priority action? 1 Refer the patient to a speech therapist. 2 Treat this as an emergency and call the health care provider. 3 Ensure the patient that he or she should not worry about the illness. 4 Ask the patient to protrude the tongue to test the hypoglossal nerve.

2 - Treat this as an emergency and call the health care provider. Obesity, high blood pressure, and diabetes are all risk factors for stroke. Sudden fumbling of the patient or sudden slurred speech is considered a transient ischemic attack (TIA) and a warning sign of stroke. It should be considered an emergency, and the health care provider should be informed. TIAs may be caused by microemboli that temporarily block the blood flow. The signs and symptoms of a TIA depend on the blood vessel that is involved and the area of the brain that is ischemic. If the carotid system is involved, patients may have a temporary loss of vision in one eye, transient hemiparesis, numbness or loss of sensation, or a sudden inability to speak. Referral to a speech therapist may not help because it is not a speech disorder. The sudden inability to speak might not be caused the by patient's worry about his or her disease or by dysfunction of the hypoglossal nerve.

A registered nurse is teaching a student nurse about tissue plasminogen activator (tPA) administration in a patient with ischemic stroke. Which statement made by the student nurse indicates a need for further teaching? 1 "tPA is administered intravenously (IV)." 2 "tPA is administered by intraarterial infusion." 3 "tPA should be administered within 12 hours of the onset of a stroke." 4 "tPA requires blood pressure monitoring during and 24 hours after the treatment."

3 - "tPA should be administered within 12 hours of the onset of a stroke." When tPA is administered to patients with an acute onset of ischemic stroke, it is administered intravenously (IV) and should be provided 3 to 4.5 hours from the onset of a stroke, not 12 hours. When administered by intraarterial infusion, tPA is delivered directly to the clot and can be administered up to 6 hours after the onset of stroke symptoms. It is important to monitor blood pressure during the treatment and for 24 hours after the fibrinolytic treatment. If blood pressure is not controlled, it can alter the fibrinolytic treatment.

The nurse is feeding a patient by mouth for the first time after a stroke. What should the nurse feed the patient at this first feeding? 1 Thin liquids 2 Pureed foods 3 Crushed ice 4 Milk products

3 - Crushed ice The first oral feeding should be approached carefully because the gag reflex may be impaired due to dysphagia. To assess the swallowing reflex, the head of the bed is elevated to an upright position and the patient is given small amounts of crushed ice to swallow. If the gag reflex is present and the patient is able to swallow safely, the feeding may be done. Thin liquids are often difficult to swallow and may promote coughing; hence, they should be avoided. Pureed foods are often bland and too smooth. Milk products tend to increase the viscosity of mucus and increase salivation.

What behavior is exhibited by a patient who has suffered a right-brain stroke? 1 Very cautious 2 Difficulty with words 3 Impulsive and impatient 4 Accomplishes tasks quickly

3 - Impulsive and impatient A patient who has suffered a stroke on the right side of the brain will behave impulsively and act impatiently. A left-brain stroke survivor is aware of the deficiency and failure in mental functioning, and is very cautious. After a stroke, a patient will be much slower while undertaking actions. Survivors of left-brain damage will experience communication problems and have difficulty with words.

A nurse is preparing a menu for a stroke patient with dysphagia. What food should be included in the diet? 1 Milkshakes 2 Chicken soup 3 Mashed potatoes 4 Pureed cooked rice

3 - Mashed potatoes Stroke patients with dysphagia have difficulty chewing and swallowing. Thus the nurse should include mashed potatoes because the food is easy to swallow and provides enough texture. Milkshakes and all milk products should be avoided because they increase the viscosity of mucus, which leads to an increase in salivation. Chicken soup is a thin liquid that may be difficult to swallow and could trigger coughing or choking. Pureed cooked rice is bland to the taste and may stick to the palate, which poses a risk for aspiration.

What precautions should the nurse follow when feeding a patient with a stroke on the left side? Select all that apply. 1 Place the patient in right lateral position. 2 Place the patient in low Fowler's position. 3 Place the patient in high Fowler's position. 4 Place the patient in Trendelenburg's position. 5 Place the patient in a chair with the head flexed forward.

3 - Place the patient in high Fowler's position. 5 - Place the patient in a chair with the head flexed forward. A person in a Fowler's position is sitting straight up or leaning slightly back. The legs may either be straight or bent. A high Fowler's position is sitting upright. This helps in feeding, as well as swallowing, for the patient. Sitting in a chair with the head flexed forward also serves a similar purpose. Low Fowler's, Trendelenburg's, and right lateral positions are not appropriate for feeding.

The patient is being evaluated for thrombolytic therapy. Which findings support the use of thrombolytic agents? Select all that apply. 1 The onset of symptoms was five hours ago. 2 The patient had a hip replacement one week ago. 3 There has been no head trauma for three months. 4 The patient's blood pressure (BP) is 180/100 mm Hg. 5 There is a recent history of gastrointestinal (GI) bleeding. 6 The computed tomographic (CT) scan is clear of hemorrhage.

3 - There has been no head trauma for three months. 4 - The patient's blood pressure (BP) is 180/100 mm Hg. 6 - The computed tomographic (CT) scan is clear of hemorrhage. To receive thrombolytic agents, the patient should have a CT scan clear of hemorrhage, no head trauma in the past three months, and a BP lower than 185/110 mm Hg. Five hours is too long to wait before administering the therapy; this should be done within three to four and a half hours since the onset of symptoms. There should be no recent history of GI bleeding. The patient should also not have had surgery within the last two weeks.

The patient was exhibiting symptoms of a stroke for two hours before the symptoms resolved. Which condition may this patient have experienced? 1 Embolic brain stroke 2 Acute brain infarction 3 Transient ischemic attack 4 Subarachnoid hemorrhage

3 - Transient ischemic attack A transient ischemic attack is a transient episode of neurologic symptoms without acute brain infarction. With acute brain infarction, cell death occurs. An embolic brain stroke is associated with a clot to the brain, which causes permanent damage. Subarachnoid hemorrhage is bleeding in the subarachnoid area.

The nurse is conducting a physical assessment for a patient in the emergency room. Which finding is consistent with a left-hemispheric stroke? 1 Good impulse control and judgment 2 Unilateral weakness of the left extremities 3 Unilateral weakness of the right extremities 4 Alert and oriented to time, place, and person

3 - Unilateral weakness of the right extremities A patient with a left-hemispheric stroke will have unilateral weakness of the right extremities. Being alert and oriented to time, place, and person is a normal assessment finding. Good impulse control and judgment are normal assessment findings. A patient with a right-hemispheric stroke will have unilateral weakness of the left extremities.

The nurse is providing education on the drug clopidogrel for a patient who experienced a transient ischemic attack (TIA). Which patient statement indicates a need for further teaching? 1 "I will let my dentist know that I started this medication." 2 "I need to be careful to avoid cutting myself when working with sharp garden tools." 3 "I need to check with my health care provider before taking any of my herbal supplements." 4 "I need to keep in close contact with my health care provider because I need frequent blood tests to adjust the medication dose."

4 - "I need to keep in close contact with my health care provider because I need frequent blood tests to adjust the medication dose." The drug clopidogrel often is prescribed after a TIA to prevent strokes. Clopidogrel is an antiplatelet aggregator aimed at preventing clot formation. This medication does not require frequent blood tests for dose adjustments like warfarin. It is important that the patient inform other health care providers and dentists about taking this medication because the medication is often stopped 10 to 14 days before surgery or dental procedures. Because many herbal products interfere with prescription medications, it is important for the patient to discuss any herbal, alternative, or over-the-counter medication use with the health care provider. Because clopidogrel prevents platelets from aggregating, the patient will experience prolonged bleeding; therefore, the patient should take extra precautions to avoid injuries or cuts.

The registered nurse is teaching a student nurse about acute care for a patient with ischemic stroke. The patient's blood pressure is 230/120 mm Hg. Which statement made by the student nurse indicates the need for further teaching? 1 "Urine output should be monitored." 2 "Fibrinolytic therapy should be given." 3 "Antihypertensive drugs should be provided." 4 "Large amounts of fluid should be provided."

4 - "Large amounts of fluid should be provided." While an adequate amount of fluid should be provided to keep the patient hydrated, overhydrating may lead to increasedcerebral edema. Urine output should be monitored to ensure that the patient does not become dehydrated. Fibrinolytic therapy helps in the lysis of clots, and should be considered in the immediate aftermath of an ischemic stroke. However, before providing the therapy, the patient's blood pressure should be less than 185/110 mm Hg. Antihypertensive drugs, such as labetalol and nicardipine, help lower high blood pressure in the patient.

The primary health care provider has prescribed nimodipine. Which nursing action is appropriate? 1 Hold if patient has expiratory wheezes. 2 Administer for temperature greater than 101° F. 3 Hold if diastolic blood pressure is less than 60 mm Hg. 4 Administer if heart rate is greater than 60 beats/minute.

4 - Administer if heart rate is greater than 60 beats/minute. Nimodipine is classified as a calcium-channel blocker that lowers both the blood pressure and the pulse rate. Nimodipine should be held if the systolic blood pressure is less than 90 mm Hg or the pulse is less than 60 beats/minute. The presence of wheezes has no relevance to nimodipine administration, nimodipine is not indicated to treat an elevated temperature, and can be given if the diastolic blood pressure is less than 60 mm Hg.

The nurse is preparing a community stroke awareness program. The nurse knows that which ethnic group has the highest incidence of stroke? 1 Asians 2 Mexicans 3 Caucasians 4 African Americans

4 - African Americans African Americans have twice the incidence of stroke related to hypertension, obesity, and diabetes. Caucasians, Mexicans, and Asians have a lower risk of stroke than do African Americans.

The patient is recovering from a stroke and is confined to bed for most of the day. For which condition is this patient at risk? 1 Fatigue 2 Malnutrition 3 Dehydration 4 Constipation

4 - Constipation A patient with poor physical mobility will have problems with constipation due to immobility and weak abdominal muscles. Fatigue is related to participation in physical activity. Malnutrition and dehydration are related to access to food and the ability to feed oneself.

The patient's vitals are a blood pressure (BP) of 180/100 mm Hg, a heart rate of 100 beats/minute, a respiratory rate of 22, and a body temperature of 98.9 F. The doctor has ordered labetalol by slow intravenous (IV) push. What is recommended for BP management after a stroke? 1 A lower BP is a protective response to maintain cerebral perfusion. 2 The BP must be lower than 180/105 mm Hg to receive fibrinolytic agents. 3 Elevated BPs are expected after a stroke, and drug therapy should be initiated. 4 Drugs to lower blood pressure are recommended if the BP is 220/120 mm Hg or higher.

4 - Drugs to lower blood pressure are recommended if the BP is 220/120 mm Hg or higher. The use of drugs to lower blood pressure is recommended if the BP is 220/120 mm Hg or higher. An elevated BP is common after a stroke and may be a protective response to maintain cerebral perfusion. The BP must be lower than 185/110 mm Hg to receive a fibrinolytic agent and must then be maintained at or below 108/105 mm Hg for 24 hours.

Which assessments would the nurse conduct that will enhance detection and responsiveness in patients experiencing a stroke? 1 Foot drop, leg weakness, speech difficulties, time 2 Facial drooping, leg weakness, garbled speech, time 3 Facial weakness, arm weakness, states disoriented 4 Facial drooping, arm weakness, speech difficulties, time

4 - Facial drooping, arm weakness, speech difficulties, time The FAST mnemonic, a quick and easy way to remember the signs of stroke according to the American Stroke Association, includes Face drooping, Arm weakness, Speech difficulties, and Time. States disoriented, Foot drop, Legs weakness, and Garbled speech are not specific to the FAST mnemonic. (The page reference for this item in Lewis 10e is 1345; Table 57-1.)

The patient has a sudden onset of symptoms including headache and vomiting. The nurse observes that the patient is also drowsy. Which condition may this patient be experiencing? 1 Embolic stroke 2 Brain infarction 3 Cerebral edema 4 Hemorrhagic stroke

4 - Hemorrhagic stroke Clinical manifestations of hemorrhagic stroke include a sudden onset of symptoms like headache and vomiting with a change in mental status. Embolic stroke and brain infarction symptoms are related to a change in mental status and functional weakness or disability. Cerebral edema has a gradual onset as the brain swells.

A patient underwent aneurysm clipping six hours ago for subarachnoid hemorrhage and is being treated with nimodipine. While examining the patient, the nurse finds that the pulse of the patient is 50 beats per minute (beats/minute) and the blood pressure is 90/60 mm Hg. What should the nurse do? 1 Encourage intake of fluids orally. 2 Monitor blood pressure every half hour. 3 Start intravenous fluids to increase blood volume. 4 Hold the medication and contact the primary health care provider.

4 - Hold the medication and contact the primary health care provider. Nimodipine is a calcium channel blocker that is given to patients with subarachnoid hemorrhage to decrease the effects of vasospasm and to minimize cerebral damage. Nimodipine lowers the blood pressure, and therefore before administration, it is important to assess the blood pressure and apical pulse. If the pulse and blood pressure drop (pulse is less than 60 beats per minute and systolic blood pressure is less than 90 mm Hg), the medication should be stopped and the primary health care provider should be contacted immediately. The nurse should not start IV fluids without contacting the health care provider first. The blood pressure may be monitored more frequently if they are in intensive care or unstable. The patient may be NPO or unable to have oral fluids at this point.

A patient presents to the emergency department reporting a sudden onset of headache described as "the worse headache ever." The patient also reports nausea and visual disturbances. What collaborative intervention is a priority for the nurse? 1 Obtain consent for lumbar puncture. 2 Administer zofran 4 mg Ondansetron (ODT) for nausea. 3 Administer morphine sulfate 4 mg intravenous push (IVP). 4 Prepare patient for transport to computed tomography (CT) scan.

4 - Prepare patient for transport to computed tomography (CT) scan. The patient is presenting with symptoms of subarachnoid hemorrhage. The priority intervention is to prepare for transport to CT for rapid recognition and diagnosis of this neurologic insult. Presenting symptoms for this neurologic emergency include sudden onset of headache that is different from previously experienced headache and typically "the worst headache of one's life." Level of consciousness may or may not be affected. Other manifestations include cranial nerve deficits, nausea, vomiting, seizures, and stiff neck. A lumbar puncture may be indicated, but only after the CT is completed and does not demonstrate hemorrhagic findings. Narcotic pain management would be used judiciously because the medication may mask changes in level of consciousness, which would indicate a decline in neurologic status. Addressing nausea, while important for patient comfort, would be important once diagnosis of the life-threatening neurologic issue is made.

The patient is identified as having modifiable risk factors for stroke. Which of these risk factors is will the nurse include in the teaching plan? 1 Age 2 Gender 3 Heredity 4 Smoking

4 - Smoking Smoking is a modifiable risk factor. Age, gender, and heredity are not modifiable.

Which intervention is most appropriate when communicating with a patient suffering from aphasia following a stroke? 1 Present several thoughts at once so that the patient can connect the ideas. 2 Ask open-ended questions to provide the patient the opportunity to speak. 3 Finish the patient's sentences to minimize frustration associated with slow speech. 4 Use simple, short sentences accompanied by visual cues to enhance comprehension.

4 - Use simple, short sentences accompanied by visual cues to enhance comprehension. When communicating with a patient with aphasia, the nurse should present one thought or idea at a time. Ask questions that can be answered with a "yes," "no," or simple word. Use visual cues, and allow time for the individual to comprehend and respond to conversation. Presenting several thoughts at once would overwhelm the patient. Asking open-ended questions would be difficult for the patient to answer. Do not finish the patient's sentences because it will case frustration on his or her part, and the nurse doesn't know for sure what the answer is.