Combo with Ch. 58 Nursing Management Stroke and 1 other – Flashcards
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In promoting health maintenance for prevention of strokes, the nurse understands that the highest risk for the most common type of stroke is present in a. African Americans b. women who smoke c.individuals with hypertension and diabetes d. those who are obese with high dietary fat intake
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C: Individuals with hypertension and diabetes- The highest risk factors for thrombotic stroke are hypertension and diabetes. African Americans have a higher risk for stroke than do white persons but probably because they have a greater incidence of hypertension. Factors such as obesity, diet high in saturated fats and cholesterol, cigarette smoking, and excessive alcohol use are also risk factors but carry less risk than hypertension.
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A thrombus that develops in a cerebral artery does not always cause a loss of neurologic function because a. the body can dissolve the atherosclerotic plaques as they form b. some tissues of the brain do not require constant blood supply to prevent damage c. circulation through the circle of Willis may provide blood supply to the affected area of the brain d. neurologic deficits occur only when major arteries are occluded by thrombus formation around an atherosclerotic plaque
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C: Circulation through the circle of Willis may provide blood supply to the affected area of the brain. The communication between cerebral arteries in the circle of Willing provides a collateral circulation, which may maintain circulation to an area of the brain if its original blood supply is obstructed. ALl areas of the brain require constant blood supply, and atherosclerotic plaques are not readily reversed. Neurologic deficits can result from ischemia cause by many factors.
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A patient comes to the emergency department immediately after experiencing numbness of the face and an inability to speak, but while the patient awaits examination, the symptoms disappear and the patient request discharge. The nurse stresses that it is important for the patient to be evaluated primarily because a. the patient has probably experienced an asymptomatic lacunar stroke b. the symptoms are likely to return and progress to worsening neurologic deficit in the next 24 hours c. neurologic deficits that are transient occur most often as a result of small hemorrhages that clot off d. the patient has probably experienced a transient ischemic attack (TIA), which is a sign of progressive cerebral vascular disease
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D: The patient has probably experienced a transient ischemic attack (TIA), which is a sign of progressive cerebral vascular disease- A TIA is a temporary focal loss of neurologic function caused by ischemia of an area of the brain, usually lasting only about 3 hours. TIAs may be due to microemboli from heart disease or carotid or cerebral thrombi and are a warning of progressive disease. Evaluation is necessary to determine the cause of the neurologic deficit and provide prophylactic treatment if possible.
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The neurologic functions that are affected by a stroke are primarily related to a. the amount of tissue area involved b. the rapidity of onset of symptoms c. the brain area perfused by the affected artery d. the presence or absence of collateral circulation
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C: The brain area perfused by the affected artery- clinical manifestation of altered neurologic function differ, depending primarily on the specific cerebral artery involved and the area of the brain that is perfused by the artery. The degree of impairment depends on rapidity of onset, the size of the lesion, and the presence of collateral circulation.
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A patient is admitted to the hospital with a left hemiplegia. To determine the size and location and to ascertain whether a stroke is ischemic or hemorrhagic, the nurse anticipates that the health care provider will request a a. CT scan b. lumbar puncture c. cerebral arteriogram d. positron emission tomography (PET)
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A: CT scan- A CT scan is the most commonly used diagnostic test to determine the size and location of the lesion and to differentiate a thrombotic stroke from a hemorrhagic stroke. Positron emission tomography (PET) will show the metabolic activity of the brain and provide a depiction of the extent of tissue damage after a stroke. Lumbar punctures are not performed routinely because of the chance of increased intracranial pressure causing herniation. Cerebral arteriograms are invasive and may dislodge an embolism or cause further hemorrhage; they are performed only when no other test can provide the needed information.
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A carotid endarterectomy is being considered as a treatment for a patient who has had several TIAs. The nurse explains to the patient that this surgery a. is used to restore blood to the brain following an obstruction of a cerebral artery b. involves intracranial surgery to join a superficial extracranial artery to an intracranial artery c. involves removing an atherosclerotic plaque in the carotid artery to prevent an impending stroke d. is sued to open a stenosis in a carotid artery with a balloon and stent to restore cerebral circulation
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C: Involves removing an atherosclerotic plaque in the carotid artery to prevent an impending stroke- An endarterectomy is a removal of an atherosclerotic plaque, and plaque in the carotid artery may impair circulation enough to cause a stroke. A carotid endarterectomy is performed to prevent a cerebrovascular accident (CVA), as are most other surgical procedures. An extacranial-intracranial bypass involves cranial surgery to bypass a sclerotic intacranial artery. Percutaneous transluminal angioplasty uses a balloon to compress stenotic areas in the carotid and vertebrobasilar arteries and often includes inserting a stent to hold the artery open.
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The incidence of ischemic stroke in patients with TIAs and other risk factors is reduced with administration of a. furosemide (Lasix) b. lovastatin (Mevacor) c. daily low dose aspirin d. nimodipine (Nimotop)
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C: Daily low dose aspirin- the administration of antiplatelet agents, such as aspirin, dipyridamole (Persantine), and ticlopdipine (Ticlid), reduces the incidence of stroke in those at risk. Anticoagulants are also used for prevention of embolic strokes but increase the risk for hemorrhage. Diuretics are not indicated for stroke prevention other than for their role in controlling BP, and antilipemic agents have bot been found to have a significant effect on stroke prevention. The calcium channel blocker nimodipine is used in patients with subarachnoid hemorrhage to decrease the effects of vasospasm and minimize tissue damage. P.S. I freaking love you and good luck on the final!!
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The priority intervention in the emergency department for the patient with a stroke is a. intravenous fluid replacement b. administration of osmotic diuretics to reduce cerebral edema c. initiation of hypothermia to decrease the oxygen needs of the brain d. maintenance of respiratory function with a patent airway and oxygen administration
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D: Maintenance of respiratory function with a patent airway and oxygen administration- the first priority in acute management of the patient with a stroke is preservation of life. Because the patient with a stroke may be unconscious or have a reduced gag reflex, it is most important to maintain a patent airway for the patient and provide oxygen if respiratory effort is impaired. IV fluid replacement, treatment with osmotic diuretics, and perhaps hypothermia may be used for further treatment.
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A diagnosis of a ruptured cerebral aneurysm has been made in a patient with manifestations of a stroke. The nurse anticipates that treatment options that would be evaluated for the patient include a. hyperventilation therapy b. surgical clipping of the aneurysm c. administration of hyperosmotic agents d. administration of thrombolytic therapy
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B: Surgical clipping of they aneurysm- Surgical management with clipping of an aneurysm to decrease re bleeding and vasospasm is an option for a stroke cause by rupture of a cerebral aneurysm. Placement of coils into the lumens of the aneurysm by intercentional radiologists is increasing in popularity. Hyperventilation therapy would increase vasodilation and the potential for hemorrhage. Thrombolytic therapy would be absolutely contraindicated, and if a vessel is patent, osmotic diuretics may leak into tissue, pulling fluid out of the vessel and increasing edema.
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During the acute phase of a stroke, the nurse assesses the patient's vital signs and neurologic status every 4 hours. A cardiovascular sign that the nurse would see as the body attempts to increase cerebral blood flow is a. hypertension b. fluid overload c. cardiac dysrhythmias d. S3 and S4 heart sounds
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A: Hypertension- The body responds to the vasopasm and a decreased circulation to the brain that occurs with a stroke by increasing the BP, frequently resulting in hypertension. The other options are important cardiovascular factors to assess, but they do not result from impaired cerebral blood flow.
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A nursing intervention is indicated for the patient with hemiplegia is a. the use of a footboard to prevent plantar flexion b. immobilization of the affected arm against the chest with a sling c. positioning the patient in bed with each joint lower than the joint proximal to it d. having the patient perform passive ROM of the affected limb with the unaffected limb
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D: Having the patient perform passive ROM of the affected limb with the unaffected limb- active ROM should be initiated on the unaffected side as soon as possible, and passive ROM of the affected side should be started on the first day. Having the patient actively exercise the unaffected side provides the patient with active and passive ROM as needed. Use of footboards is controversial because they stimulate plantar flexion. The unaffected arm should be supported, but immobilization may precipitate a painful shoulder-hand syndrome. The patient should be positioned with each joint higher than the joint proximal to it to prevent dependent edema.
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A newly admitted patient who has suffered a right sided brain stroke has a nursing diagnosis of disturbed visual sensory perception related to homonymous hemianopsia. Early in the care of the patient, the nurse should a. place objects on the right side within the patient's field of vision b. approach the patient from the left side to encourage the patient to turn the head c. place objects on the patient's left side to assess the patient's ability to compensate d. patch the affected eye to encourage the patient to turn the head to scan the environment
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A: Place objects on the right side within the patient's field of vision- the presence of homonymous hemianopia in a patient with right-hemisphere brain damage causes a loss of vision in the left field. Early in the care of the patient, objects should be placed on the right side of the patient in the field of vision, and the nurse should approach the patient from the right side. Later in treatment, patients should be taught to turn the head and scan the environment and should be approached from the affected side to encourage head turning. Eye patches are used if patients have diplopia (double vision).
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Four days following a stroke, a patient is to start oral fluids and feedings. Before feeding the patient, the nurse should first a. check the patient's gag reflex b. order a soft diet for the patient c. raise the head of the bed to sitting position d. evaluate the patient's ability to swallow small sips of ice water
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A: check the patient's gag reflex- the first step in providing oral feedings for a patient with a stroke is ensuring that the patient has an intact gag reflex because oral feedings will not be provided if gag reflex is impaired. The nurse should then evaluate the patient's ability to swallow ice chips or ice water after placing the patient in an upright position
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An appropriate food for a patient with a stroke who has mild dysphagia is a. fruit juices b. pureed meat c. scrambled eggs d. fortified milkshakes
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C: scrambled eggs- soft foods that provide enough texture, flavor, and bulk to stimulate swallowing should be used for the patient with dysphasia. Thin liquids are difficult to swallow, and patients may not be able to control them in the mouth. Pureed foods are often too bland and to smooth, and milk products should be avoided because they tend to increase the viscosity of mucus and increase salivation.
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A patient's wife asks the nurse why her husband did not receive the clot busting medication (tPA) she has been reading about. Her husband is diagnosed with a hemorrhagic stroke. What should the nurse respond? a. He didn't arrive within the time frame for that therapy b. Not every is eligible for this drug. Has he had surgery lately? c. You should discuss the treatment of your husband with your doctor d. The medication you are talking about dissolves clots and could cause more bleeding in your husband's head
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D: The medication you are talking about dissolves clots and could cause more bleeding in your husband's head- tPA dissolves clots and increases the risk for bleeding. It is not used with hemorrhagic strokes. If the patient had a thrombotic/embolic stroke the time frame would be important as well as a history of surgery. The nurse should answer the question as accurately as possible and then encourage the individual to talk with the primary care physician if he or she has further questions.
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To promote communication during rehabilitation of the patient with aphasia, an appropriate nursing intervention is to a. use gestures, pictures, and music to stimulate patient responses b. talk about activities of daily living (ADLs) that are familiar to the patient c. structure statements so that patient does not have to respond verbally d. use flashcards with simple words and pictures to promote language recall
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B: Talk about ADLs that are familiar to the patient- during rehabilitation, the patient with aphasia needs frequent, meaningful verbal stimulation that has relevance for him. Conversation by the nurse and family should address ADLs that are familiar to the patient. Gestures, pictures, and simple statements are more appropriate in the acute phase, when patients may be overwhelmed with verbal stimuli. Flashcards are often perceived by the patient as childish and meaningless.
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A patient with right hemisphere stroke has a nursing diagnosis of unilateral neglect related to sensory perceptual deficits. During the patient's rehabilitation, it is important for the nurse to a. avoid positioning the patient on the affected side b. place all objects for care on the patient's unaffected side c. teach the patient to care consciously for the affected side d. protect the affected side from injury with pillows and supports
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C: Teach the patient to care consciously for the affected side- unilateral neglect, or neglect syndrome, occurs when the patient with a stroke is unaware of the affected side of the body, which puts the patient at risk for injury. During the acute phase, the affected side is cared for by the nurse with positioning and support, during rehabilitation the patient is taught to care consciously for and attend to the affected side of the body to protect it from injury. Patients may be positioned on the affected side for up to 30 minutes.
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A patient with a stroke has a right sided hemiplegia. The nurse prepares family members to help control behavior changes seen with this type of stroke by teaching them to a. ignore undesirable behaviors manifested by the patient b. provide directions to the patient verbally in small steps c. distract the patient from inappropriate emotional responses d. supervise all activities before allowing the patient to pursue them independently
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C: Distract the patient from inappropriate emotional responses- patients with left-sided brain damage from stroke often experience emotional lability, inappropriate emotional responses, mood swings, and uncontrolled tears or laughter disproportionate or out of context with the situation. The behavior is upsetting and embarrassing to both the patient and the family, and the patient should be distracted to minimize its presence. Patients with right-brain damage often have impulsive, rapid behavior that supervision and direction.
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The nurse can assist the patient and the family in coping with the long term effects of a stroke by a. informing family members that the patient will need assistance with almost all ADLs b. explaining that the patient's prestroke behavior will return as improvement progresses c. encouraging the patient and family members to seek assistance from family therapy or stroke support groups d. helping the patient and family understand the significance of residual stroke damage to promote problem solving and planning
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D: Helping the patient and family understand the significance of residual stroke damage to promote problem solving and planning- the patient and family need accurate and complete information about the effects of the stroke to problem solve and make plans for chronic care of the patient. It is uncommon for patients with major strokes to return completely to pre stroke function, behaviors, and role, and both the patient and family will mourn these losses. The patient's specific needs for care must be identified, and rehabilitation efforts should be continued at home. Family therapy and support groups may be helpful for some patients and families.
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Which intervention should the nurse delegate to the LPN when caring for a patient following an acute stroke? a. assess the patient's neurologic status b. assess the patient's gag reflex before beginning feeding c. administer ordered antihypertensives and platelet inhibitors d. teach the patient's caregivers strategies to minimize unilateral neglect
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C: Administer ordered antihypertensives and platelet inhibitors- medication administration is within the scope of practice for an LPN. Assessment and teaching are within the scope of practice for the RN.
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Characteristics of a thrombotic stroke
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Type most often signaled by TIAs, commonly occurs during or after sleep, strong association with hypertension
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Characteristics of embolic stroke
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Onset unrelated to activity, quick onset and resolution, associated with endocardial disorders
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Characteristics of intracerebral hemorrhage
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Rupture of atherosclerotic vessels, carries the poorest prognosis, creates mass that compresses the brain
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Characteristics of subarachnoid hemorrhage
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High initial mortality, symptoms of meningeal irritation, caused by rupture of intracranial aneurysm, associated with sudden, severe headache
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Manifestations of left brain damage
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Aphasia, inability to remember words
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Manifestations of right brain damage
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Left homonymous hemianopsia, agnosia, quick impulsive behavior, neglect of the left side of the body
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Which of the following is the best treatment for acute ischemic stroke? a. heparin b. LMWH c. Alteplase d. Eptifibatie e. Warfarin Which of the following is the best treatment for acute ischemic stroke? a. heparin b. LMWH c. Alteplase d. Eptifibatie e. Warfarin
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C: Alteplase
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1st thing you do when you suspect a stroke
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Non-contrast CT scan (determines hemorrhagic vs ischemic)
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Most common artery involved
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Internal Carotid Artery
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Permissive hypertension
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If you drop blood pressure then more green tissue (ischemic) turns red (infarcted) (only treat BP if >200)
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Treat for hemorrhagic stroke
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Lower BP
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Problem with IV-TPA
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only 1-3% of patients arrive in time to receive it
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Arterial sources of stroke (3)
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1. Intracranial vascular disease 2. Carotid vascular disease 3. Aortic arch
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Secondary prevention of stroke (3)
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1. Anticoagulants 2. Antiplatelets 3. Surgery
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Secondary prevention: Risk factor modification (4)
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1. smoking cessation 2. diabetes control 3. aggressive cholesterol lowering 4. hypertension control
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4 major causes of hemorrhagic stroke
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1)deep hypertensive intracerebral hemorrhages, 2)ruptured saccular aneurysms, 3)arteriovenous malformation,4)spontaneous lobar hemorrhages
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The nurse obtains all of the following information about a 65-year-old patient in the clinic. When developing a plan to decrease stroke risk, which risk factor is most important for the nurse to address? a. The patient smokes a pack of cigarettes daily. b. The patient's blood pressure (BP) is chronically between 150/80 to 170/90 mm Hg. c. The patient works at a desk and relaxes by watching television. d. The patient is 25 pounds above the ideal weight.
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Correct Answer: B Rationale: Hypertension is the most important modifiable risk factor. Smoking, physical inactivity, and obesity all contribute to stroke risk but not so much as hypertension. Cognitive Level: Application Text Reference: p. 1503 Nursing Process: Assessment NCLEX: Health Promotion and Maintenance
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A patient with right-sided weakness that started 1 hour ago is admitted to the emergency department and all these diagnostic tests are ordered. Which order should the nurse act on first? a. Noncontrast computed tomography (CT) scan b. Chest radiograph c. Complete blood count (CBC) d. Electrocardiogram (ECG)
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Correct Answer: A Rationale: Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 3 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the smaller the area of brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.
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The nurse expects that management of the patient who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects will include a. heparin via continuous intravenous infusion. b. prophylactic clipping of cerebral aneurysms. c. therapy with tissue plasminogen activator (tPA). d. oral administration of ticlopidine (Ticlid).
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Correct Answer: D Rationale: The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, but not for TIA. Cognitive Level: Application Text Reference: p. 1505 Nursing Process: Implementation NCLEX: Physiological Integrity
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Aspirin is ordered for a patient who is admitted with a possible stroke. Which information obtained during the admission assessment indicates that the nurse should consult with the health care provider before giving the aspirin? a. The patient has atrial fibrillation. b. The patient has dysphasia. c. The patient states, "I suddenly developed a terrible headache." d. The patient has a history of brief episodes of right hemiplegia.
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Correct Answer: C Rationale: A sudden-onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack (TIA) are not contraindications to aspirin use, so the nurse can administer the aspirin. Cognitive Level: Application Text Reference: p. 1507 Nursing Process: Assessment NCLEX: Physiological Integrity
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A patient with a stroke experiences right-sided arm and leg paralysis and facial drooping on the right side. When obtaining admission assessment data about the patient's clinical manifestations, it is most important the nurse assess the patient's a. ability to follow commands. b. visual fields. c. right-sided reflexes. d. emotional state.
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Correct Answer: A Rationale: Because the patient with a left-sided brain stroke may also have difficulty with comprehension and use of language, so it is important to obtain baseline data about the ability to follow commands. This will impact on patient safety and nursing care. The visual fields are not typically affected by a left-sided stroke. Information about reflexes and emotional state will be collected but is not as high a priority as information about language abilities. Cognitive Level: Application Text Reference: p. 1508 Nursing Process: Assessment NCLEX: Physiological Integrity
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6. The nurse on the medical unit receives a verbal report from the emergency department nurse that a patient has an occlusion of the left posterior cerebral artery. When admitting the patient to the medical floor, the nurse will anticipate that the patient may have a. visual deficits. b. dysphasia. c. confusion. d. poor judgment.
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Correct Answer: A Rationale: Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with middle cerebral artery involvement. Cognitive deficits and changes in judgment are more typical of anterior cerebral artery occlusion. Cognitive Level: Application Text Reference: p. 1507 Nursing Process: Assessment NCLEX: Physiological Integrity
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The health care provider prescribes clopidogrel (Plavix) for a patient with cerebral atherosclerosis. When teaching about the new medication, the nurse will tell the patient a. that Plavix will reduce cerebral artery plaque formation. b. to monitor and record the blood pressure daily. c. to call the health care provider if stools are tarry. d. that Plavix will dissolve clots in the cerebral arteries.
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Correct Answer: C Rationale: Plavix inhibits platelet function and increases the risk for gastrointestinal bleeding, so patients should be advised to notify the health care provider about any signs of bleeding. The medication does not lower blood pressure, decrease plaque formation, or dissolve clots. Cognitive Level: Application Text Reference: p. 1510 Nursing Process: Implementation NCLEX: Physiological Integrity
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The health care provider recommends a carotid endarterectomy for a patient with carotid atherosclerosis and a history of transient ischemic attacks (TIA). The patient asks the nurse to describe the procedure. Which response by the nurse is appropriate? a. "The diseased portion of the artery in the brain is removed and replaced with a synthetic graft." b. "The carotid endarterectomy involves surgical removal of plaque from an artery in the neck." c. "A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque." d. "A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed."
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Correct Answer: B Rationale: In a carotid endarterectomy, the carotid artery is incised and the plaque is removed. The response beginning, "The diseased portion of the artery in the brain is removed" describes an arterial graft procedure. The answer beginning, "A catheter with a deflated balloon is positioned at the narrow area" describes an angioplasty. The final response (beginning, "A wire is threaded through the artery") describes the Merci procedure. Cognitive Level: Application Text Reference: p. 1510 Nursing Process: Implementation NCLEX: Physiological Integrity
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On initial assessment of a patient hospitalized following a stroke, the nurse finds the patient's blood pressure to be 180/90 mm Hg. Which of the following orders by the health care provider should the nurse question? a. Infuse normal saline at 75 ml/hr. b. Keep head of bed elevated at least 30 degrees. c. Administer tissue plasminogen activator (tPA) per protocol. d. Titrate labetolol (Normodyne) drip to keep BP less than 140/90 mm Hg.
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Correct Answer: D Rationale: Since elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if MAP is >130 mm Hg or systolic pressure is >220 mm Hg. Fluid intake should be 1500 to 2000 ml daily to maintain cerebral blood flow. The head of the bed should be elevated to at least 30 degrees unless the patient has symptoms of poor tissue perfusion. tPA may be administered if the patient meets the other criteria for tPA use. Cognitive Level: Application Text Reference: p. 1511 Nursing Process: Implementation NCLEX: Physiological Integrity
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A patient with a history of several transient ischemic attacks (TIAs) arrives in the emergency room with hemiparesis and dysarthria that started 2 hours previously. The nurse anticipates the need to prepare the patient for a. intravenous heparin administration. b. transluminal angioplasty. c. surgical endarterectomy. d. tissue plasminogen activator (tPA) infusion.
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Correct Answer: D Rationale: The patient's history and clinical manifestations suggest an acute ischemic stroke and a patient who is seen within 3 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy are not indicated for the patient who is having an acute ischemic stroke. Cognitive Level: Application Text Reference: p. 1512 Nursing Process: Planning NCLEX: Physiological Integrity
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The nurse identifies the nursing diagnosis of impaired verbal communication for a patient with expressive aphasia. An appropriate nursing intervention to help the patient communicate is to a. ask simple questions that the patient can answer with "yes" or "no." b. develop a list of words that the patient can read and practice reciting. c. have the patient practice facial and tongue exercises to improve motor control necessary for speech. d. prevent embarrassing the patient by changing the subject if the patient does not respond in a timely manner.
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Correct Answer: A Rationale: Communication will be facilitated and less frustrating to the patient when questions that require a "yes" or "no" response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to respond. Cognitive Level: Application Text Reference: p. 1520 Nursing Process: Implementation NCLEX: Physiological Integrity
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A patient with a stroke has progressive development of neurologic deficits with increasing weakness and decreased level of consciousness (LOC). The priority nursing diagnosis for the patient is a. risk for impaired skin integrity related to immobility. b. disturbed sensory perception related to brain injury. c. risk for aspiration related to inability to protect airway. d. impaired physical mobility related to weakness.
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Correct Answer: C Rationale: Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other diagnoses are also appropriate, but interventions to prevent aspiration are the priority at this time. Cognitive Level: Application Text Reference: p. 1515 Nursing Process: Diagnosis NCLEX: Physiological Integrity
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A patient has a stroke affecting the right hemisphere of the brain. Based on knowledge of the effects of right brain damage, the nurse establishes a nursing diagnosis of a. impaired physical mobility related to right hemiplegia. b. impaired verbal communication related to speech-language deficits. c. risk for injury related to denial of deficits and impulsiveness. d. ineffective coping related to depression and distress about disability.
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Correct Answer: C Rationale: Right-sided brain damage typically causes denial of any deficits and poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability. Cognitive Level: Application Text Reference: p. 1508 Nursing Process: Diagnosis NCLEX: Physiological Integrity
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14. A patient with homonymous hemianopsia resulting from a stroke has a nursing diagnosis of disturbed sensory perception related to hemianopsia. To help the patient learn to compensate for the deficit during the rehabilitation period, the nurse should a. apply an eye patch to the affected eye. b. approach the patient on the unaffected side. c. place objects necessary for activities of daily living on the patient's affected side. d. have the patient use the eye muscles to move the eyes through the entire visual field.
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Correct Answer: C Rationale: During the rehabilitation period, placing objects on the affected side will encourage the patient to use the scanning technique to visualize the affected side. Because homonymous hemianopsia affects half the visual field in each eye, use of an eye patch is not appropriate. Approaching the patient on the affected side is appropriate during the acute period but does not help the patient learn skills needed to compensate for the visual defect. The problem is with the visual field, not with the eye muscles, so practice moving the eyes through the visual field will not be effective. Cognitive Level: Application Text Reference: p. 1517 Nursing Process: Implementation NCLEX: Physiological Integrity
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A patient who has had a subarachnoid hemorrhage is being cared for in the intensive care unit. Which information about the patient is most important to communicate to the health care provider? a. The patient complains of an ongoing severe headache. b. The patient's blood pressure is 90/50 mm Hg. c. The cerebrospinal fluid (CFS) report shows red blood cells (RBCs). d. The patient complains about having a stiff neck.
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Correct Answer: B Rationale: To prevent cerebral vasospasm and maintain cerebral perfusion, blood pressure needs to be maintained at a high level after a subarachnoid hemorrhage. A low or drop in BP indicates a need to administer fluids and/or vasopressors to increase the BP An ongoing headache, RBCs in the CSF, and a stiff neck are all typical clinical manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the health care provider. Cognitive Level: Analysis Text Reference: p. 1515 Nursing Process: Assessment NCLEX: Physiological Integrity
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he nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to inability to feed self for a patient with right-sided hemiplegia. An appropriate nursing intervention is to a. assist the patient to eat with the left hand. b. provide oral care before and after meals. c. teach the patient the "chin-tuck" technique. d. provide a wide variety of food choices.
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Correct Answer: A Rationale: Because the nursing diagnosis indicates that the patient's imbalanced nutrition is related to the right-sided hemiplegia, the appropriate interventions will focus on teaching the patient to use the left hand for self-feeding. The other interventions are appropriate for patients with other etiologies for the imbalanced nutrition. Cognitive Level: Application Text Reference: p. 1522 Nursing Process: Implementation NCLEX: Physiological Integrity
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17. The nurse is assisting the patient who is recovering from an acute stroke and has right-side hemiplegia to transfer from the bed to the wheelchair. Which action by the nurse is appropriate? a. Positioning the wheelchair next to the bed on the patient's right side b. Placing the wheelchair parallel to the bed on the patient's left side c. Setting the wheelchair directly in front of the patient, who is sitting on the side of the bed d. Moving the wheelchair a few steps from the bed and having the patient walk to the chair
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Correct Answer: B Rationale: Placing the wheelchair on the patient's left side will allow the patient to use the left hand to grasp the left arm of the chair to transfer. If the chair is placed on the patient's right side or in front of the patient, it will be awkward to use the strong arm, and the patient will be at increased risk for a fall. Because the patient has hemiplegia, it is not appropriate to place the chair where the patient will need to walk to it. Cognitive Level: Application Text Reference: p. 1522 Nursing Process: Implementation NCLEX: Physiological Integrity
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A 32-year-old patient has a stroke resulting from a ruptured aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan? a. Encouraging patient to cough and deep breath every 4 hours b. Inserting an oropharyngeal airway to prevent airway obstruction c. Assisting to dangle on edge of bed and assess for dizziness d. Applying intermittent pneumatic compression stockings
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Correct Answer: D Rationale: The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for deep vein thrombosis (DVT). Activities (such as coughing and sitting up) that might increase intracranial pressure (ICP) or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate. Cognitive Level: Application Text Reference: p. 1518 Nursing Process: Planning NCLEX: Physiological Integrity
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A patient who has had a stroke has a new order to attempt oral feedings. The nurse should assess the gag reflex and then a. offer the patient a sip of juice. b. order a varied pureed diet. c. assess the patient's appetite. d. assist the patient into a chair.
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Correct Answer: D Rationale: The patient should be as upright as possible before attempting feeding to make swallowing easier and decrease aspiration risk. To assess swallowing ability, the nurse should initially offer water or ice to the patient. Pureed diets are not recommended because the texture is too smooth. The patient may have a poor appetite, but the oral feeding should be attempted regardless. Cognitive Level: Application Text Reference: pp. 1518-1519 Nursing Process: Implementation NCLEX: Physiological Integrity
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A patient has right-sided weakness and aphasia as a result of a stroke but is attempting to use the left hand for feeding and other activities. The patient's wife insists on feeding and dressing him, telling the nurse, "I just don't like to see him struggle." A nursing diagnosis that is most appropriate in this situation is a. situational low self-esteem related to increasing dependence on others. b. interrupted family processes related to effects of illness of a family member. c. disabled family coping related to inadequate understanding by patient's spouse. d. ineffective therapeutic regimen management related to hemiplegia and aphasia.
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Correct Answer: C Rationale: The information supports the diagnosis of disabled family coping because the wife does not understand the rehabilitation program. There are no data supporting low self-esteem, and the patient is attempting independence. The data do not support an interruption in family processes because this may be a typical pattern for the couple. The patient's attempts to use the left hand indicate that he is managing the therapeutic regimen appropriately. Cognitive Level: Application Text Reference: p. 1523 Nursing Process: Diagnosis NCLEX: Psychosocial Integrity
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Several weeks after a stroke, a patient has urinary incontinence resulting from an impaired awareness of bladder fullness. A bladder retraining program for the patient should include a. limiting fluid intake to 1000 ml daily to reduce urine volume. b. assisting the patient onto the bedside commode every 2 hours. c. performing intermittent catheterization after each voiding to check for residual urine. d. using an external "condom" catheter to protect the skin and prevent embarrassment.
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Correct Answer: B Rationale: Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full bladder. A 1000-ml fluid intake is too restricted and will lead to dehydration. Intermittent catheterization and use of a condom catheter are appropriate in the acute phase of stroke but should not be considered solutions for long-term management because of the risks for urinary tract infection (UTI) and skin breakdown. Cognitive Level: Application Text Reference: p. 1523 Nursing Process: Planning NCLEX: Physiological Integrity
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A 72-year-old is being discharged home following a stroke. The patient is able to walk with assistance but needs help with hygiene, dressing, and eating. Which statement by the patient's wife indicates that discharge planning goals have been met? a. "I can provide the care my husband needs if I use the support and resources available in the community." b. "Because my husband will have continuous improvement in his condition, I won't need outside assistance in his care for very long." c. "I can handle all of my husband's needs thanks to the instructions you've given me." d. "I have arranged for a home health aide to provide all the care my husband will need."
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Correct Answer: A Rationale: The statement that community resources will be used indicates a realistic outcome. The patient is unlikely to continue to improve to the point of needing no assistance. The wife is likely to be overwhelmed by the patient's needs if she attempts to manage without assistance. There is no indication that the patient will need a home health aide to meet all of his care needs. Cognitive Level: Application Text Reference: p. 1524 Nursing Process: Evaluation NCLEX: Physiological Integrity
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A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering the medications, the patient says, "I don't need the aspirin today. I don't have any aches or pains." Which action should the nurse take? a. Document that the aspirin was refused by the patient. b. Call the health care provider to clarify the medication order. c. Explain that the aspirin is ordered to decrease stroke risk. d. Tell the patient that the aspirin is used to prevent aches.
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Correct Answer: C Rationale: Aspirin is ordered to prevent stroke in patients who have experienced TIAs. Documentation of the patient's refusal to take the medication is an inadequate response by the nurse. There is no need to clarify the order with the health care provider. The aspirin is not ordered to prevent aches and pains. Cognitive Level: Application Text Reference: pp. 1505, 1510 Nursing Process: Implementation NCLEX: Physiological Integrity
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A patient is admitted to the hospital with dysphasia and right-sided weakness that resolves in a few hours. The nurse will anticipate teaching the patient about a. alteplase (tPA). b. aspirin (Ecotrin). c. warfarin (Coumadin). d. nimodipine (Nimotop).
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Correct Answer: B Rationale: Following a TIA, patients typically are started on medications such as aspirin to inhibit platelet function and decrease stroke risk. tPA is used for acute ischemic stroke. Coumadin is usually used for patients with atrial fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage. Cognitive Level: Application Text Reference: pp. 1505, 1510 Nursing Process: Planning NCLEX: Physiological Integrity
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The nurse is caring for a patient with carotid artery narrowing who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse? a. The pulse rate is 104 beats/min. b. There are fine crackles at the lung bases. c. The patient has difficulty talking. d. The blood pressure is 142/88 mm Hg.
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Correct Answer: C Rationale: Small emboli can occur during carotid artery angioplasty and stenting, and the aphasia indicates a possible stroke during the procedure. Slightly elevated pulse rate and blood pressure are not unusual as a result of anxiety associated with the procedure. Fine crackles at the lung bases may indicate atelectasis caused by immobility during the procedure; the nurse should have the patient take some deep breaths. Cognitive Level: Application Text Reference: p. 1510 Nursing Process: Assessment NCLEX: Physiological Integrity
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A patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? a. Obtain the Glasgow Coma Scale score. b. Check the respiratory rate. c. Monitor the blood pressure. d. Send the patient for a CT scan.
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Correct Answer: B Rationale: The initial nursing action should be to assess the airway and take any needed actions to assure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, circulation) are completed. Cognitive Level: Application Text Reference: p. 1511
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A patient with sudden-onset right-sided weakness has a CT scan and is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? a. The patient has atrial fibrillation and takes warfarin (Coumadin). b. The patient takes a diuretic because of a history of hypertension. c. The patient's blood pressure is 144/90 mm Hg. d. The patient's speech is difficult to under
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Correct Answer: A Rationale: The use of warfarin will have contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patient's care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated. Cognitive Level: Application Text Reference: p. 1512 Nursing Process: Assessment NCLEX: Physiological Integrity
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A patient with a left-sided brain stroke suddenly bursts into tears when family members visit. The nurse should a. explain to the family that depression is normal following a stroke. b. have the family members leave the patient alone for a few minutes. c. teach the family that emotional outbursts are common after strokes. d. use a calm voice to ask the patient to stop the crying behavior.
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Correct Answer: C Rationale: Patients who have left-sided brain stroke are prone to emotional outbursts, which are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient's outburst suggests that depression is not the major cause of the behavior. The family should stay with the patient. The crying is not within the patient's control and asking the patient to stop will lead to embarrassment. Cognitive Level: Application Text Reference: p. 1523 Nursing Process: Implementation NCLEX: Psychosocial Integrity
