Question 1

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

Accepted Answer

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.

Question 2

A patient who has had a stroke has a new order to attempt oral feedings. The nurse should assess the gag reflex and then

Accepted Answer

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.

Question 3

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?

Accepted Answer

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.

Question 4

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

Accepted Answer

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.

Question 5

The nurse expects that management of the patient who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects will include

Accepted Answer

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.

Question 6

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

Accepted Answer

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.

Question 7

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

Accepted Answer

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.

Question 8

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?

Accepted Answer

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.

Question 9

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

Accepted Answer

Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with middle cerebral artery involvement.

Question 10

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

Accepted Answer

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.

Question 11

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?

Accepted Answer

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.

Question 12

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?

Accepted Answer

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.

Question 13

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

Accepted Answer

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.

Question 14

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?

Accepted Answer

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.

Question 15

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

Accepted Answer

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.

Question 16

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?

Accepted Answer

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.

Question 17

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?

Accepted Answer

Hypertension is the most important modifiable risk factor. Smoking, physical inactivity, and obesity all contribute to stroke risk but not so much as hypertension.

Question 18

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?

Accepted Answer

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.

Question 19

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

Accepted Answer

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.

Question 20

The 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

Accepted Answer

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.

Quiz 58: Nursing Management: Stroke