HESI MED STROKE

HESI MED STROKE The ED nurse is completing the admission assessment. Nancy is alert but struggles to answer questions. When she attempts to talk, she slurs her speech and appears very frightened. Which additional clinical manifestations should the nurse expect to find if Nancy's symptoms have been caused by a brain attack (stroke)? A. Difficulty swallowing B. Decreased bowel sounds C. A carotid bruit D. Elevated blood pressure E. Hyperreflexic deep tendon reflexes A. Difficulty swallowing - Difficulty swallowing can accompany a brain attack, placing the client at risk for aspiration. C. A carotid bruit - The carotid artery (artery to the brain) is narrowed in clients with a brain attack (stroke). A bruit is an abnormal sound heard on auscultation resulting from interference with normal blood flow. D. Elevated blood pressure - When a client has a brain attack (stroke), the blood pressure will often respond by going up. Increased BP is a sign of increased intracranial pressure. The ED physician has completed an assessment. Gail is sitting at the bedside while the ED nurse continues to assess Nancy every 15 minutes. Which assessment finding warrants immediate intervention by the nurse? A. Nancy has a negative Babinski's reflex bilaterally B. Nancy only responds to a painful stimuli C. Nancy's Glasgow Coma Scale (GCS) score increases D. Nancy's bilateral grip strength is unequal B. Nancy only responds to painful stimuli - This decrease in responsiveness warrants immediate intervention by the nurse, indicating a worsening condition (increased intracranial pressure). Due to her deteriorating condition, Nancy is immediately referred to the neurologist. The ED nurse realizes that Nancy has probably suffered a left-sided brain attack. Which clinical manifestation further supports this assessment? A. Spatial-perceptual deficits. B. Visual field deficit on the left side C. Paresthesia of the left side D. Global aphasia D. Global aphasia -Global aphasia refers to difficulty speaking, listening, and writing. Symptoms vary from person to person. Aphasia may occur secondary to any brain injury involving the left hemisphere. The neurologist writes a diagnosis of "Suspected brain attack" and prescribes a non contrast computed tomography (CT) scan STAT. Which nursing intervention should the nurse implement when preparing Nancy and her daughter for this procedure? A. Explain to the daughter that her mother will have to remain still throughout the CT scan B. Determine if the client has any allergies to iodine C. Provide an explanation of relaxation exercises prior to the procedure D. Premedicate the client to decrease pain prior to having the procedure A. Explain to the daughter that her mother will have to remain still throughout the CT scan. -Because head motion will distort the images, Nancy will have to remain still throughout the procedure. Since Nancy has decreased LOC, she may require head support to accomplish this. The neurologist also prescribes a magnetic resonance imaging (MRI) of the head STAT. Which data warrants immediate intervention by the nurse concerning this diagnostic test? A. Allergy to shellfish B. History of atrial fibrillation C. Right hip replacement D. Elevated blood pressure C. Right hip replacement -The magnetic field generated by the MRI is so strong that metal-containing items are strongly attracted to the magnet. Because the hip joint is made of metal, a lead shield must be used during the procedure. Nancy is transferred to the Intermediate Care Unit after the MRI is completed. She has a 20 gauge saline lock in her right forearm and an 18 French indwelling (Foley) catheter. Gail is sitting by her mother's bed. The nurse asks Gail if there is anyone that can be called so she won't be alone. She informs the nurse that she is an only child and her father died years ago. Gail states, "I don't understand what a brain attack is. The healthcare provider told me my mother is in serious condition and they are going to run several tests. I just don't know what's going on. What happened to my mother?" Which response is best by the nurse? A. "How do you feel about what the healthcare provider said?" B. "Your mother has had a stroke, and the blood supply to the brain has been compromised." C. "I will call the healthcare provider so he/she can talk to you about your mother's serious condition." D. "I am sorry, but what happened to your mother is confidential and I cannot give you any information." B. "Your mother has had a stroke, and the blood supply to the brain has been compromised." -The nurse has the knowledge, and the responsibility, to explain Nancy's condition to Gail. Gail starts to cry and states, "Mom was just fine last week when we went out to eat and to a show. I love my mom so much, and I am so scared. She is all I have." How should the nurse respond? A. "I am sure everything will be all right." B. "I will notify the chaplain to come and sit with you so you won't be alone." C. "I know this is scary for you. Would you like to sit and talk?" C. "I am sure your mother knows you are here. Just keep talking to her." C. "I know this is scary for you. Would you like to sit and talk? -This therapeutic response provides acknowledgment of Gail's fears, and the nurse offers to take time to discuss the situation. With a diagnosis of a brain attack (stroke), which priority intervention should the nurse include in Nancy's plan of care? A. Monitor INR daily B. Assess neurological status every shift C. Keep the head of the bed elevated D. Evaluate platelet levels daily C. Keep the head of the bed elevated - Maintaining a patent airway is essential to support oxygenation and cerebral perfusion. Elevating the head of the bed 30 degrees aids in preventing the tongue from falling backward and obstructing the airway. The nurse continues to monitor Nancy's condition closely. Which finding would require immediate intervention by the nurse? A. Nancy's pulse oximeter reading is greater than 95% B. Nancy's serum potassium level is 3.9 mEq/L C. Nancy's telemetry shows normal sinus rhythm with occasional premature ventricular contractions D. Nancy's cardiac output is less than 4 L/min D. Nancy's cardiac output is less than 4 L/min - The normal range for cardiac output to ensure cerebral blood flow and oxygen delivery is 4 to 8 L/min. Though Nancy's SaO2 potassium level, and telemetry readings are within normal limits for her age, her cardiac output is low. Which nursing interventions would be priority at this time? A. Monitor capillary refill every 2-4 hours B. Monitor level of consciousness C. Monitor vital signs every shift D. Strict intake and output E. Contact physician A. Monitor capillary refill every 2-4 hours - Decreased cardiac output would affect tissue perfusion, reflected in a capillary refill of greater than 3 seconds. B. Monitor level of consciousness - With a decreased cardiac output, cerebral perfusion will be affected. This can be reflected in a further decreased level of consciousness. D. Strict intake and output - The kidneys use 25% of cardiac output, so when cardiac output is decreased, the kidneys may start failing. Close monitoring is essential. E. Contact physician - The physician needs to be notified regarding decreased cardiac output to decide whether to initiate IV fluids if hypovolemia is an issue and to determine other medical interventions. As the nurse assesses Nancy, Gail asks, "Why isn't my mother a candidate for thrombolytic therapy?" A. "Since your mother was alert on admission, she is not a candidate to receive this medication. B. "I think that is something you should discuss with your mother's healthcare provider." C. "tPA is usually not administered to anyone older than 65 years." D. "She is not a candidate because of therapeutic time constraints related to this medication." D. "She is not a candidate because of therapeutic time constraints related to this medication." - Thrombolytic therapy is contraindicated in clients with symptom onset longer than 3 hours prior to admission. Nancy had symptoms for 24 hours before being brought to the medical center. Which nursing diagnosis has the highest priority? A. Impaired physical mobility B. Impaired swallowing C. Self-care deficit D. Impaired social interaction B. Impaired swallowing - According to Maslow's Hierarchy of Needs, physiological needs should be addressed first. Therefore, Nancy's dysphagia is the highest priority nursing diagnosis since she is at risk for aspiration. Because Nancy is right-handed and is having difficulty performing activities of daily living with the left arm, the nurse also includes the nursing diagnosis "self-care deficit" in the care plan. Which intervention would the nurse implement to address this nursing diagnosis? A. Use narrow grip utensils to accommodate a weak grasp B. Recommend a regular type toilet seat with grab hand bars C. Utilize plate guards when Nancy is eating D. Discourage Nancy from using assistive devices C. Utilize plate guards when Nancy is eating - Plate guards prevent food from being pushed off the plate. Using plate guards and other assistive devices will encourage independence in a client with a self-care deficit. Which condition is considered a non-modifiable risk factor for a brain attack? A. High cholesterol levels B. Obesity C. History of atrial fibrillation D. Advanced age D. Advanced age - People over age 55 are a high-risk group for a brain attack because the incidence of stroke more than doubles in each successive decade of life. Non-modifiable risk factor means the client cannot do anything to change the risk factor. Gail tells the nurse she is going to go outside to smoke a cigarette and will only be gone for a few minutes. Which statement is warranted in this situation? A. "Make sure you smoke in the smoking area only. The hospital has strict rules." B. "I should let you know that smoking is a strong risk factor for a brain attack." C. "That is just fine. I will be here taking care of your mother." D. "How long have you been smoking?" B. "I should let you know that smoking is a strong risk factor for a brain attack." - The nurse should teach Gail that smoking is a modifiable risk factor that could prevent her from having a stroke. Smoking increases the risk for hypertension, which is a risk factor for a stroke. Nancy is experiencing homonymous hemianopsia as a result of her brain attack. Which nursing intervention would the nurse implement address this condition? A. Request that the dietary department thicken all liquids on Nancy's meal and snack trays. B. Turn Nancy every 2 hours and perform active range of motion exercises. C. Speak slowly and clearly to assist Nancy in forming sounds to words D. Place the objects Nancy needs for activities of daily living on the left side of the table. D. Place the objects Nancy needs for activities of daily living on the left side of the table. - Homonymous hemianopsia is loss of the visual field on the same side as the paralyzed side. This results in the client neglecting that side of the body, so it is beneficial to place objects on that side. Nancy had a left-hemisphere brain attack so her right side is the weak side. Nancy is experiencing pain in her right shoulder. The nurse is aware that up to 70% of clients with a brain attack experience severe pain in the shoulder that prevents them from learning new skills. Shoulder function helps clients achieve balance, perform transfer skills, and participate in self-care activities.Which intervention should the nurse implement when addressing this condition? A. Move Nancy by lifting with the affected shoulder B. Assist Nancy to keep the affected arm in a dependent position as much as possible C. Instruct Nancy to clasp the right hand with the left hand and raise both hands above the head D. Remind Nancy to perform active range of motion exercises daily C. Instruct Nancy to clasp the right hand with the left hand and raise both hands above the head - This exercise helps prevent "frozen shoulder" and will aid the nurse when moving or positioning the client. Gail tells the nurse, "One of the people in the waiting room was telling me about an operation that her mother had to prevent a stroke. Do you know anything about that?" A. "There is currently no surgery that can help prevent a stroke." B. "I am sure your healthcare provider will discuss that with you at a later date." C. "That procedure is only done with small strokes, not like the one your Mom had." D. "Yes, it is a carotid endarterectomy, and your mother may be able to have one." C. "That procedure is only done with small strokes,not like the one your Mom had." - This surgery is indicated for clients with symptoms of transient ischemic attack (TIA), or mild stroke, found to be due to severe carotid artery stenosis or moderate stenosis with other significant risk factors. Which nursing care task should the nurse delegate to the UAP? A. Assist Nancy to eat her breakfast B. Use a walker to help Nancy ambulate down the hall C. Give Nancy a bed bath and change the bed linens D. Flush Nancy's saline lock with 2 ml of normal saline C. Give Nancy a bed bath and change the bed linens - The UAP can assist Nancy with bathing and then change the bed linens. This task does not require professional judgment or expertise Which written documentation should the nurse put in the client's record? A. PT reported that client became dizzy and was lowered back to the bed with the assistance of a gait belt B. PT notified the primary nurse that the client could not ambulate at this time because of dizziness C. Client had difficulty ambulating from the bed to the chair when accompanied by the PT, variance report completed D. Client experienced orthostatic hypotension when getting out of bed A. PT reported that client became dizzy and was lowered back to the bed with the assistance of a gait belt - This documentation provides the factual data of the events that occurred. Which intervention should the nurse implement to prevent joint deformities? A. Place the elbow lower than the shoulder and the wrist lower than the elbow on the affected side. B. Position the fingers so that they are totally flexed in a slight pronation position. C. Place Nancy in a pone position for 15 minutes at least 4 times a day. D. Apply splints to the arms and legs during the day but remove at night C. Place Nancy in a prone position for 15 minutes at least 4 times a day - This helps to promote hyperextension of the hip joints, which helps prevent knee and hip flexion contractures. Which rehabilitation team member is responsible for evaluating Nancy's dysphagia? A. The occupational therapist B. The rehabilitation physician C. The case manager D. The speech therapist D. The speech therapist - The speech therapist evaluates the e client's gag reflex and ability to swallow, then makes recommendations regarding feeding techniques and diet. After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual effects, the nurse anticipates teaching the patient about a. cerebral aneurysm clipping. b. heparin intravenous infusion. c. oral low-dose aspirin therapy. d. tissue plasminogen activator (tPA). C. 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, not for TIA. A 68-year-old patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin? a. The patient has dysphasia. b. The patient has atrial fibrillation. c. The patient reports that symptoms began with a severe headache. d. The patient has a history of brief episodes of right-sided hemiplegia. C. 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. A 73-year-old patient with a stroke experiences facial drooping on the right side and right-sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find? a. Impulsive behavior b. Right-sided neglect c. Hyperactive left-sided tendon reflexes d. Difficulty comprehending instructions D. Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with comprehension and use of language. The left-side reflexes are likely to be intact. Impulsive behavior and neglect are more likely with a right-side stroke. During the change of shift report a nurse is told that a patient has an occluded left posterior cerebral artery. The nurse will anticipate that the patient may have a. dysphasia. b. confusion. c. visual deficits. d. poor judgment. C. 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. When teaching about clopidogrel (Plavix), the nurse will tell the patient with cerebral atherosclerosis a. to monitor and record the blood pressure daily. b. that Plavix will dissolve clots in the cerebral arteries. c. that Plavix will reduce cerebral artery plaque formation. d. to call the health care provider if stools are bloody or tarry. D. Clopidogrel (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. A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which response by the nurse is accurate? a. "The obstructing plaque is surgically removed from an artery in the neck." b. "The diseased portion of the artery in the brain is replaced with a synthetic graft." c. "A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed." d. "A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque." A. 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 replaced" 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 mechanical embolus removal in cerebral ischemia (MERCI) procedure. A patient admitted with possible stroke has been aphasic for 3 hours and his current blood pressure (BP) is 174/94 mm Hg. Which order by the health care provider should the nurse question? a. Keep head of bed elevated at least 30 degrees. b. Infuse normal saline intravenously at 75 mL/hr. c. Administer tissue plasminogen activator (tPA) per protocol. d. Administer a labetalol (Normodyne) drip to keep BP less than 140/90 mm Hg. D. Because elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if mean arterial pressure (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. A 56-year-old patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously, and health records show a history of several transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for a. surgical endarterectomy. b. transluminal angioplasty. c. intravenous heparin administration. d. tissue plasminogen activator (tPA) infusion. D. The patient's history and clinical manifestations suggest an acute ischemic stroke and a patient who is seen within 4.5 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 is not indicated for the patient who is having an acute ischemic stroke. A female patient who had a stroke 24 hours ago has expressive aphasia. The nurse identifies the nursing diagnosis of impaired verbal communication. An appropriate nursing intervention to help the patient communicate is to a. ask 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 her facial and tongue exercises with a mirror. d. prevent embarrassing the patient by answering for her if she does not respond. A. 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. A 72-year-old patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the patient says, "I don't need the aspirin today. I don't have a fever." Which action should the nurse take? a. Document that the aspirin was refused by the patient. b. Tell the patient that the aspirin is used to prevent a fever. c. Explain that the aspirin is ordered to decrease stroke risk. d. Call the health care provider to clarify the medication order. C. 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. For a patient who had a right hemisphere stroke the nurse establishes a nursing diagnosis of a. risk for injury related to denial of deficits and impulsiveness. b. impaired physical mobility related to right-sided hemiplegia. c. impaired verbal communication related to speech-language deficits. d. ineffective coping related to depression and distress about disability. A. The patient with right-sided brain damage typically denies any deficits and has 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. A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours. The nurse will anticipate teaching the patient about a. alteplase (tPA). b. aspirin (Ecotrin). c. warfarin (Coumadin). d. nimodipine (Nimotop). B. Following a transient ischemic attack (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. When caring for a patient with a new right-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care? a. Apply an eye patch to the right eye. b. Approach the patient from the right side. c. Place objects needed on the patient's left side. d. Teach the patient that the left visual deficit will resolve. C. During the acute period, the nurse should place objects on the patient's unaffected side. Because there is a visual defect in the right half of each eye, an eye patch is not appropriate. The patient should be approached from the left side. The visual deficit may not resolve, although the patient can learn to compensate for the defect. A 58-year-old patient with a left-brain stroke suddenly bursts into tears when family members visit. The nurse should a. use a calm voice to ask the patient to stop the crying behavior. b. explain to the family that depression is normal following a stroke. c. have the family members leave the patient alone for a few minutes. d. teach the family that emotional outbursts are common after strokes. D. Patients who have left-sided brain stroke are prone to emotional outbursts that 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. The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to impaired self-feeding ability for a left-handed patient with left-sided hemiplegia. Which intervention should be included in the plan of care? a. Provide a wide variety of food choices. b. Provide oral care before and after meals. c. Assist the patient to eat with the right hand. d. Teach the patient the "chin-tuck" technique. C. Because the nursing diagnosis indicates that the patient's imbalanced nutrition is related to the leftsided hemiplegia, the appropriate interventions will focus on teaching the patient to use the right hand for self-feeding. The other interventions are appropriate for patients with other etiologies for the imbalanced nutrition. Which stroke risk factor for a 48-year-old male patient in the clinic is most important for the nurse to address? a. The patient is 25 pounds above the ideal weight. b. The patient drinks a glass of red wine with dinner daily. c. The patient's usual blood pressure (BP) is 170/94 mm Hg. d. The patient works at a desk and relaxes by watching television. C. Hypertension is the single most important modifiable risk factor. People who drink more than 1 (for women) or 2 (for men) alcoholic beverages a day may increase risk for hypertension. Physical inactivity and obesity contribute to stroke risk but not as much as hypertension. A 40-year-old patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan? a. Apply intermittent pneumatic compression stockings. b. Assist to dangle on edge of bed and assess for dizziness. c. Encourage patient to cough and deep breathe every 4 hours. d. Insert an oropharyngeal airway to prevent airway obstruction. A. The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thromboembolism (VTE). 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. A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? a. The patient's speech is difficult to understand. b. The patient's blood pressure is 144/90 mm Hg. c. The patient takes a diuretic because of a history of hypertension. d. The patient has atrial fibrillation and takes warfarin (Coumadin). D. The use of warfarin probably 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. A 47-year-old patient will attempt oral feedings for the first time since having a stroke. The nurse should assess the gag reflex and then a. order a varied pureed diet. b. assess the patient's appetite. c. assist the patient into a chair. d. offer the patient a sip of juice. C. 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. A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first? a. Complete blood count (CBC) b. Chest radiograph (Chest x-ray) c. 12-Lead electrocardiogram (ECG) d. Noncontrast computed tomography (CT) scan D. Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 4.5 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the less 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. A male patient who has right-sided weakness after a stroke is making progress in learning to use the left hand for feeding and other activities. The nurse observes that when the patient's wife is visiting, she feeds and dresses him. Which nursing diagnosis is most appropriate for the patient? a. Interrupted family processes related to effects of illness of a family member b. Situational low self-esteem related to increasing dependence on spouse for care c. Disabled family coping related to inadequate understanding by patient's spouse d. Impaired nutrition: less than body requirements related to hemiplegia and aphasia C. 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. There is no indication that the patient has impaired nutrition. Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness (LOC). Which nursing diagnosis do they determine has the highest priority for the patient? a. Impaired physical mobility related to weakness b. Disturbed sensory perception related to brain injury c. Risk for impaired skin integrity related to immobility d. Risk for aspiration related to inability to protect airway D. 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. Several weeks after a stroke, a 50-year-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention will be best to include in the initial plan for an effective bladder training program? a. Limit fluid intake to 1200 mL daily to reduce urine volume. b. Assist the patient onto the bedside commode every 2 hours. c. Perform intermittent catheterization after each voiding to check for residual urine. d. Use an external "condom" catheter to protect the skin and prevent embarrassment. B. Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full bladder. A 1200 mL fluid restriction may 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. Which information about the patient who has had a subarachnoid hemorrhage is most important to communicate to the health care provider? a. The patient complains of having a stiff neck. b. The patient's blood pressure (BP) is 90/50 mm Hg. c. The patient reports a severe and unrelenting headache. d. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs). B. To prevent cerebral vasospasm and maintain cerebral perfusion, blood pressure needs to be maintained at a level higher than 90 mm Hg systolic after a subarachnoid hemorrhage. A low BP 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. The nurse is caring for a patient who has been experiencing stroke symptoms for 60 minutes. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Assess the patient's gag and cough reflexes. b. Determine when the stroke symptoms began. c. Administer the prescribed short-acting insulin. d. Infuse the prescribed IV metoprolol (Lopressor). C. Administration of subcutaneous medications is included in LPN/LVN education and scope of practice. The other actions require more education and scope of practice and should be done by the registered nurse (RN). After receiving change-of-shift report on the following four patients, which patient should the nurse see first? a. A 60-year-old patient with right-sided weakness who has an infusion of tPA prescribed b. A 50-year-old patient who has atrial fibrillation and a new order for warfarin (Coumadin) c. A 40-year-old patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due d. A 30-year-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine (Nimotop) scheduled A. tPA needs to be infused within the first few hours after stroke symptoms start in order to be effective in minimizing brain injury. The other medications should also be given as quickly as possible, but timing of the medications is not as critical. The nurse is caring for a patient 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 102 beats/min. b. The patient has difficulty speaking. c. The blood pressure is 144/86 mm Hg. d. There are fine crackles at the lung bases. B. 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 because 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. A 70-year-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? a. Monitor the blood pressure. b. Send the patient for a computed tomography (CT) scan. c. Check the respiratory rate and effort. d. Assess the Glasgow Coma Scale score. C. The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, and circulation) are completed. The home health nurse is caring for an 81-year-old who had a stroke 2 months ago. Based on information shown in the accompanying figure from the history, physical assessment, and physical therapy/occupational therapy, which nursing diagnosis is the highest priority for this patient? a. Impaired transfer ability b. Risk for caregiver role strain c. Ineffective health maintenance d. Risk for unstable blood glucose level B. The spouse's household and patient care responsibilities, in combination with chronic illnesses, indicate a high risk for caregiver role strain. The nurse should further assess the situation and take appropriate actions. The data about the control of the patient's diabetes indicates that ineffective health maintenance and risk for unstable blood glucose are not priority concerns at this time. Because the patient is able to ambulate with a cane, the nursing diagnosis of impaired transfer ability is not supported. A 63-year-old patient who began experiencing right arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol? a. Obtain computed tomography (CT) scan without contrast. b. Infuse tissue plasminogen activator (tPA). c. Administer oxygen to keep O2 saturation >95%. d. Use National Institute of Health Stroke Scale to assess patient. C, D, A, B The initial actions should be those that help with airway, breathing, and circulation. Baseline neurologic assessments should be done next. A CT scan will be needed to rule out hemorrhagic stroke before tPA can be administered. Which additional clinical manifestations should the RN expect to find if these symptoms Mrs. Jackson has have been caused by a brain attack (stroke)? (Select all that apply) A. Carotid bruit B. Elevated BP E. Drooling Which assessment finding warrants immediate intervention by the RN? (Select all that apply) C. Mrs. Jackson only response to painful stimuli D. Positive Babinski's reflex bilaterally E. Pupils are reacting unequally, and she is experiencing sensitivity to light What clinical manifestation further supports this assessment? D) Global aphasia. Rationale: Global aphasia refers to difficulty speaking, listening, and understanding, as well as difficulty reading and writing. Symptoms vary from person to person. Aphasia may occur secondary to any brain injury involving the left hemisphere. Visual field deficits, spatial-perceptual deficits, and paresthsia of the left side usually occur with right-sided brain attack. Which intervention should the RN implement when preparing Mrs. Jackson and her daughter for this procedure? B) Explain to the daughter that her mother will have to remain still throughout the CT scan. Rationale: Because head motion will distort the images, Nancy will have to remain still throughout the procedure. Allergies to iodine is important if contrast dye is being used for the CT scan. Premedicating the client to decrease pain prior to the procedure is unnecessary because CT scanning is a noninvasive and painless procedure. Providing an explanation of relaxation exercises prior to the procedure is a worthwhile intervention to decrease anxiety but is not of highest priority. A neurologist prescribes a magnetic resonance imaging (MRI) of the head STAT for a patient. Which data warrants immediate intervention by the nurse concerning this diagnostic test? C) Right hip replacement. The magnetic field generated by the MRI is so strong that metal-containing items are strongly attracted to the magnet. Because the hip joint is made of metal, a lead shield must be used during the procedure. Elevated blood pressure, an allergy to shell fish, and a history of atrial fibrillation would not affect the MRI. Gail, the daughter states, "I don't understand what a brain attack is. The healthcare provider told me my mother is in serious condition and they are going to run several tests. I just don't know what is going on. What happened to my mother?" What is the best response by the nurse? B) "Your mother has had a stroke, and the blood supply to the brain has been blocked." Rationale: The nurse can discuss what a diagnosis means. Nancy is unable to make decisions, so the next of kin, her daughter, Gail, needs sufficient information to make informed decisions. The nurse has the knowledge, and the responsibility, to explain Nancy's condition to Gail. The nurse should give facts first, and then address her feelings after the information is provided. Gail begins to cry and states, "Mom was just fine last week when we went out to eat and to a show. I love my mom so much, and I am so scared. She is all I have." How should the RN respond? B. I know this is scary for you. Would you like to sit and talk? The neurologist diagnosis I'd ask you make a left sided brain attack, stroke. The neurologist determines that Mrs. Jackson is not a candidate for tissue plasminogen activator, tPA. Enoxaparin 1 mg/kg subcutaneously every 12 hours is prescribed. Mrs. Jackson weighs 145 pounds. How many milligrams of Enoxaparin Will the nurse administer in each dose? 66 mg 145/2.2 = 65.9kg x 1mg/kg = approx. 66 mg With a diagnosis of a brain attack, stroke, which priority intervention should the RN include and Mrs. Jackson's plan of care? C. Keep the head of the bed elevated Maintaining a patent airway is essential to support oxygenation and cerebral perfusion. Elevating the head of the bed 30 degrees aids in preventing the tongue from falling backward and obstructing the airway. The nurse continues to monitor Nancy's condition closely. Which finding would require immediate intervention by the nurse? A. Nancy's cardiac output is less than 4 L/min The normal range for cardiac output to ensure cerebral blood flow and oxygen delivery is 4 to 8 L/min. Though Nancy's SaO2 potassium level, and telemetry readings are within normal limits for her age, her cardiac output is low. Which nursing interventions would be priority at this time? A. Monitor level of consciousness With a decreased cardiac output, cerebral perfusion will be affected. This can be reflected in a further decreased level of consciousness. C. Strict intake and output The kidneys use 25% of cardiac output, so when cardiac output is decreased, the kidneys may start failing. Close monitoring is essential. D. Monitor capillary refill every 2-4 hours Decreased cardiac output would affect tissue perfusion, reflected in a capillary refill of greater than 3 seconds. E. Contact physician The physician needs to be notified regarding decreased cardiac output to decide whether to initiate IV fluids if hypovolemia is an issue and to determine other medical interventions. As the nurse assesses Nancy, Gail asks, "Why isn't my mother a candidate for thrombolytic therapy?" B. "She is not a candidate because of therapeutic time constraints related to this medication." Thrombolytic therapy is contraindicated in clients with symptom onset longer than 3 hours prior to admission. Nancy had symptoms for 24 hours before being brought to the medical center. Which nursing diagnosis has the highest priority? D. Drooling According to Maslow's Hierarchy of Needs, physiological needs should be addressed first. Therefore, Nancy's dysphagia is the highest priority nursing diagnosis since she is at risk for aspiration. Because Nancy is right-handed and is having difficulty performing activities of daily living with the left arm, the nurse also includes the nursing diagnosis "self-care deficit" in the care plan. Which intervention would the nurse implement to address this nursing diagnosis? B. Utilize plate guards when Nancy is eating Plate guards prevent food from being pushed off the plate. Using plate guards and other assistive devices will encourage independence in a client with a self-care deficit. Which condition is considered a modifiable risk factor for a brain attack? A. High cholesterol levels B. Obesity C. HTN D. Hx of A.fib Gail tells the nurse she is going to go outside to smoke a cigarette and will only be gone for a few minutes. Which statement is warranted in this situation? A. "I should let you know that smoking is a strong risk factor for a brain attack." The nurse should teach Gail that smoking is a modifiable risk factor that could prevent her from having a stroke. Smoking increases the risk for hypertension, which is a risk factor for a stroke. Nancy is experiencing homonymous hemianopsia as a result of her brain attack. Which nursing intervention would the nurse implement address this condition? B. Place the objects Nancy needs for activities of daily living on the left side of the table. Homonymous hemianopsia is loss of the visual field on the same side as the paralyzed side. This results in the client neglecting that side of the body, so it is beneficial to place objects on that side. Nancy had a left-hemisphere brain attack so her right side is the weak side. Mrs. Jackson is experiencing pain in her right shoulder. The nurse is aware that up to 70% of clients with a brain attack experience severe pain in the shoulder that prevents them from learning new skills. Shoulder function helps clients achieve balance, perform transfer skills, and participate in self-care activities.Which intervention should the nurse implement when addressing this condition? D. Instruct Mrs. Jackson to clasp the right hand with the left hand and raise both hands above the head This exercise helps prevent "frozen shoulder" and will aid the nurse when moving or positioning the client. Gail tells the nurse, "One of the people in the waiting room was telling me about an operation that her mother had to prevent a stroke. Do you know anything about that?" How should the RN respond? B. "That procedure is only done with small strokes,not like the one your Mom had." This surgery is indicated for clients with symptoms of transient ischemic attack (TIA), or mild stroke, found to be due to severe carotid artery stenosis or moderate stenosis with other significant risk factors. Which nursing care task should the nurse delegate to the UAP? D. Give Mrs. Jackson a bed bath and change the bed linens The UAP can assist Nancy with bathing and then change the bed linens. This task does not require professional judgment or expertise Which written documentation should the nurse put in the client's record? B. PT reported that client became dizzy and was lowered back to the bed with the assistance of a gait belt - This documentation provides the factual data of the events that occurred. Which intervention should the nurse implement to prevent joint deformities? A. Place Nancy in a prone position for 15 minutes at least 4 times a day This helps to promote hyperextension of the hip joints, which helps prevent knee and hip flexion contractures. Which action should the RN implement to address this situation? C. Discuss how to use a communication board w/ both Mrs. Jackson and her daughter. Which rehabilitation team member is responsible for evaluating Mrs. Jackson's dysphagia? B. The speech therapist The speech therapist evaluates the e client's gag reflex and ability to swallow, then makes recommendations regarding feeding techniques and diet. The RN notes that Mrs. Jackson is no longer able to meet her nutritional needs and has lost 10 lbs.A gastrostomy tube is prescribed so that intermittent tube feedings can be administered. Which intervention should the RN implement first? A. Elevate the head of the bed to a semi-fowler's position during the feeding. Prevents aspiration At what rate would the RN set the infusion pump? B. 60 ml/hr The RN assesses Mrs. Jackson's apical pulse but cannot hear anything. Which intervention should the RN implement first? B. Continue to stay at Mrs. Jackson's bedside and hold Gail's hand. The telephone at Mrs. Jackson's bedside starts ringing. The RN answers the phone. The caller is one of Mrs. Jackson's neighbors, wanting to know how Mrs. Jackson is doing. How should the nurse respond? C. I am sorry, but I am unable to give you any information The RN remains with Gail at Mrs. Jackson bedside. The HCP is called an pronounces Mrs. Jackson's death. Gail tells the RN that Mrs. Jackson wanted to be in organ donor. Which action should the RN implement? B. Explain that Mrs. Jackson can only be a tissue donor, not an organ donor. Mrs. Jackson was a Roman Catholic so Gail ask for the RN if Mrs. Jackson can receive, the sacrament for the sick. Which action would be most important for the RN to take in the situation? B. Have a priest perform Mrs. Jackson's anointing of the sick Gail wants to bury her mother beside her father in the local cemetery and tells the RN, I just don't know what I should do. How should the RN respond? C. You seem really confused about what to do. Would you like to talk about it? 1. A patient has weakness on the right side and impaired reasoning after having a cerebrovascular accident (CVA). What part of the brain is affected? a. Left hemisphere of the cerebrum b. Right hemisphere of the cerebrum c. Left cerebellum d. Right cerebellum ANS: A Impaired motor strength on the right side in conjunction with impaired reasoning indicates a lesion in the left hemisphere of the cerebrum. The cerebellum controls balance and is not contralateral. 2. Which patient is at the greatest risk for a CVA? a. A 20-year-old obese Latin woman who is taking birth control pills b. A 40-year-old athletic white man with a family history of CVA c. A 60-year-old Asian woman who smokes occasionally d. A 65-year-old African American man with hypertension ANS: D Older African Americans have a higher incidence of CVA than occasional smokers, young persons, or athletes. Hypertension increases the risk. 3. A patient experienced a period of momentary confusion, dizziness, and slurred speech but recovered in 2 hours. Which assessment in the diagnosis of this episode would be most helpful? a. Patient's complaint of nausea b. Blood pressure (BP) of 140/90 mm Hg c. Patient's complaint of headache d. Auscultation of a bruit over the carotid artery ANS: D A carotid bruit is evidence of a narrowing in that vessel, a symptom of a possible CVA or transient ischemic attack (TIA). BP of 140/90 mm Hg, although at the high end, is considered within normal limits. Headache and nausea alone are too common to be definitive. 4. A nurse is updating a teaching plan for a patient who sustained a TIA. What should the nurse be sure to include? a. Daily aspirin dose b. Long rest periods daily c. Reduction of fluid intake to 800 mL/day d. High-carbohydrate diet ANS: A Daily aspirin reduces platelet aggregation and may prevent another attack. Reductions of fluid and long rest periods encourage clot formation. 5. A patient recovering from a CVA asks the purpose of the warfarin (Coumadin). What is the best response by the nurse regarding the purpose of Coumadin? a. Dissolves the clot. b. Prevents the formation of new clots. c. Dilates the vessels to improve blood flow. d. Suppresses the formation of platelets. ANS: B Coumadin and heparin prevent more clots rather than dissolving them. Coumadin has no effect on vasodilation or blood cell production. 6. A patient has had a complete stroke as a result of a ruptured vessel in the left hemisphere. How should this patient's CVA be classified? a. Ischemic, embolic b. Hemorrhagic, subarachnoid c. Hemorrhagic, intracerebral d. Ischemic, thrombotic ANS: C A ruptured vessel in a hemisphere is an intracerebral hemorrhagic CVA. It did not occur in the subarachnoid space. Ischemic CVAs are the result of occluded vessels. 7. What should a nurse ensure as a priority for a patient immediately after a CVA? a. Preservation of motor function b. Airway maintenance c. Adequate hydration d. Control of elimination ANS: B Adequate oxygenation prevents hypoxemia, which can extend and worsen effects of the CVA. 8. When should a nurse recognize that the acute phase of a CVA has ended? a. Forty-eight hours has passed from its onset. b. The patient begins to respond verbally. c. BP drops. d. Vital signs and neurologic signs stabilize. ANS: D When the vital and neurologic signs stabilize, the acute phase has ended. Verbal response, lower BP, and the passage of time without other signs are not adequate evidence that the acute phase has ended. 9. A patient in the acute phase of a CVA who has been speaking distinctly begins to speak indistinctly and only with great effort but still coherent. What should this nurse determine when assessing this patient? a. Stroke in evolution with dysarthria b. Lacunar stroke with fluent aphasia c. Complete stroke with global aphasia d. Stroke in evolution with dyspraxia ANS: A As symptoms worsen, the CVA is still evolving. Speech that is coherent but difficult is dysarthria rather than any type of aphasia. Dyspraxia is a motor impairment, not a speech impairment. 10. Several days after a CVA, a patient's family asks a nurse if tissue plasminogen activator (tPA) is a drug therapy option now. The nurse's response is based on the knowledge that this drug must be used within how many hours after the onset of symptoms? a. 3 b. 5 c. 10 d. 24 ANS: A tPA is to be given within 3 hours of the onset of symptoms per the U.S. Food and Drug Administration's guidelines. In some special treatment centers this drug is given intravenously up to 6 hours after the stroke. 11. A nurse explains that a lumbar puncture is most helpful as a diagnostic tool for a new patient who has had a CVA. What would this diagnostic test help determine regarding the stroke? a. It is lacunar. b. It is hemorrhagic or embolic. c. It is complete or in evolution. d. It will result in paralysis. ANS: B Blood in the spinal fluid indicates a hemorrhagic stroke and will help direct medical protocol in the subsequent treatment. 12. A patient who has sustained a hemorrhagic stroke is placed on a protocol of 60 mg of calcium channel blocker (nimodipine) every 4 hours. The patient's pulse is 82 beats/min before the administration of the prescribed dose. Which action should the nurse implement? a. Give the full dose as prescribed without further assessment. b. Omit the dose, recording the pulse rate as the rationale. c. Delay the dose until the pulse is below 60 beats/min. d. Give half of the prescribed dose (30 mg). ANS: A The dose should be given; it would be held only if the pulse is below 60 beats/min. Assessments should be made regarding BP, urine output, and edema. 13. During the acute CVA phase, a risk for falls related to paralysis is present. Which intervention best protects the patient from injury? a. Keep the bed in a high position for ease of nursing care. b. Keep the side rails up, according to agency policy. c. Assess vision deficit related to ptosis. d. Monitor the condition every 2 hours. ANS: B Rails keep patients in bed. The bed should be low, monitoring the patient should be more frequent than every 2 hours, and visual assessment is not directly related to fall prevention. 14. Pneumonia is the most frequent cause of death after a stroke. Which intervention would be contraindicated in the acute care of a patient with a hemorrhagic CVA? a. Thicken liquids to ease swallowing and prevent aspiration. b. Change position every 30 to 60 minutes. c. Maintain adequate fluid intake, orally or IV. d. Encourage forceful coughing to stimulate deep breathing. ANS: D Forceful coughing is contraindicated for the patient with a hemorrhagic CVA because it may cause increased intracranial pressure. 15. Which assessment indicates a fluid volume excess in a patient in the acute phase of a CVA? a. Decreased BP b. Weak pulse c. Adventitious breath sounds d. High urine-specific gravity ANS: C Crackles in the lung fields are a major indicator of fluid excess. The pulse and BP are elevated in fluid excess. Urine-specific gravity is low in fluid excess. 16. Which intervention should the nurse include in a patient's plan of care to help preserve joint mobility in the acute phase of a CVA? a. Pull the limbs on the affected side into a functional position. b. Perform aggressive full range-of-motion exercises for all extremities. c. Support affected points in good functional alignment. d. Exercise the limbs every 8 hours. ANS: C Limbs maintained in a functional anatomic position and gently exercised (never pulled) into an acceptable range of motion several times during a shift will maintain optimal mobility. 17. A patient in the acute phase of an embolic CVA has an order for 400 units of heparin per hour IV. The heparin is in a solution of 5000 units/100 mL normal saline (NS). The nurse should set the electronic IV monitor at how many milliliters per hour? a. 6 b. 8 c. 10 d. 16 ANS: B Regardless of the method of calculation, 50 units of heparin are in each milliliter of the solution; 8 mL/hr delivers 400 units (5000 units ÷ 100 mL NS = 50 units/mL. 400 units ÷ 50 units/mL = 8 mL). 18. Which assessment indicates that a patient with a CVA is in transition to the rehabilitation phase? a. BP has been within normal limits for 24 hours. b. Patient makes positive statements about his condition. c. No further neurologic deficits are observed. d. Successful attempts are made at independent function. ANS: C When no further deficits are noted and all vital signs have stabilized, the patient is considered to be in the rehabilitation phase. Positive statements and attempts at independence are not sufficient. 19. A patient with homonymous hemianopsia is in the rehabilitation phase of a CVA. When arranging this patient's environment where should the nurse assure persons approaching and important items are visible and available? a. Unaffected side b. Affected side c. Direct front d. Either side ANS: B Making the patient scan the affected side helps stimulate the return of normal function in the rehabilitation phase. 20. Which outcome criterion is the most appropriate for a patient with "Imbalanced nutrition, related to dysphagia, with the goal of adequate nutrition"? a. Offers a variety of food groups b. Eats half of all meals offered c. Maintains body weight of 150 to 155 lb d. Eats all meals independently ANS: C The maintenance of a desired weight is indicative of adequate nutrition. Eating a portion of a meal or eating independently does not adequately measure the extent to which the goal was met. Offering a variety of foods is a nursing or dietary function, not an outcome. 21. Which is the most effective intervention for best support of regular bowel elimination and the prevention of constipation? a. Limit fluid intake from 32 to 50 oz daily to compact the stool. b. Administer small soapsuds enema every other day to cleanse the bowel. c. Give stool softeners daily, establishing a consistent time to attempt elimination. d. Administer a strong laxative on a daily basis to encourage evacuation. ANS: C Daily stool softeners, rather than daily laxatives or frequent enemas, help restore regularity and bowel tone. 22. A patient in the rehabilitation phase after a CVA accidentally knocks the adapted plate from the table and bursts into tears after failing to feed himself. What is the best response by the nurse? a. "Don't cry. You'll be mastering eating in no time." b. "I don't believe crying will help. Let's try drinking from a special cup." c. "Bless your heart! Let me get a new meal and feed you." d. "Learning new skills is hard. Let's see what may have caused the trouble." ANS: D Recognizing effort and showing support are the best approaches to depression and frustration. Babying the patient and admonitions against crying add to the problem. Redirection to the task at hand is therapeutic. 23. Which instruction is most helpful in teaching the family and patient who is in the rehabilitation phase after a CVA about altered sensation? a. Make frequent assessments for signs of pressure or injury. b. Use the affected side in supporting the patient in ambulation and transfer to stimulate better sensation. c. Apply ice packs to the affected limbs to encourage a return of sensation. d. Apply a heating pad to the affected limbs to increase circulation. ANS: A Frequent assessment using the National Institutes of Health Stroke Scale will allow early detection. The use of hot or cold applications and using the affected limbs in transfer or ambulation may cause injury. 24. Which posthospital option should the nurse encourage a patient to do when recovering from a CVA to provide the most comprehensive assistance? a. Transfer to a rehabilitation center. b. Discharge to home with scheduled visits from home health care nurses. c. Discharge to home with scheduled visits from a physical therapist. d. Discharge to home with scheduled visits from an occupational therapist. ANS: A A rehabilitation center with all modalities of support (e.g., physical therapy, occupational therapy, speech therapy, simulated home environments) is obviously the best option. 25. The wife of a husband who has had a CVA asks why he is being treated with insulin since he has no history of diabetes. What is the best response by the nurse as to why hyperglycemia occurs after a stroke? a. Brain swelling b. Hypertension c. Immobility d. Stress ANS: D Hyperglycemia occurs after a CVA as the body's response to stress. If left untreated, the hyperglycemia will cause increased brain damage and worsen the outcome of the stroke. 26. Which transitory symptoms might occur when a patient is diagnosed with a TIA? (Select all that apply.) a. Incontinence b. Dysphagia c. Ptosis d. Tinnitus e. Dysarthria ANS: B, C, D, E All, except transitory incontinence, are classic symptoms of a TIA. These deficits usually disappear without permanent disability in approximately 24 hours. 27. What purposes exist for a stent in the carotid artery of a person with a TIA? (Select all that apply.) a. Capture circulating clots. b. Help with subsequent angioplasties. c. Keep the artery open. d. Prevent hemorrhage. e. Measure the pressure in the artery. ANS: C The only purpose of a stent is to keep an artery open. 28. What signs and symptoms characterize expressive aphasia? (Select all that apply.) a. Speech that sounds normal but makes no sense b. Total inability to communicate c. Difficulty understanding the written and spoken word d. Stuttering and spitting e. Difficulty initiating speech ANS: E Expressive aphasia makes it difficult for the patient to initiate speech. 29. How does a lacunar stroke differ from an ischemic CVA? (Select all that apply.) a. Causes a great deal of pain b. Alters the personality c. Affects small arteries d. Nearly always results in blindness e. Produces a small amount of neurologic damage ANS: C, E The lacunar CVA only affects small arteries and produces a small amount of neurologic damage. 30. Which patients with CVAs are considered candidates for treatment with tPA? (Select all that apply.) a. A 62-year-old construction worker who had a subdural hematoma 6 months earlier b. A 58-year-old executive with a bleeding ulcer c. A 44-year-old individual who had a seizure at the onset of a stroke d. A 40-year-old individual who is taking warfarin (Coumadin) and has an INR of 2.5 e. A 19-year-old young adult with leukemia with a platelet count of 200,000 ANS: A, E The criteria for exclusion are a head injury within the last