Nur 325 Exam 3 Questions and
Answers
Lumbar puncture nursing management - ANSWER-lie flat for 2-6 hours afterward
Can bleed or get a very bad HA
Encourage to drink fluids
Monitor for increased temp which could progress to meningitis and difficulty voiding
Contraindications of Lumbar puncture - ANSWER-Increased ICP which can lead to
brainstem herniation
Ipsilateral - ANSWER-same side is effected
contralateral - ANSWER-opposite side is effected
Modifiable risk factors for stroke - ANSWER-Smoking, htn, obesity, CAD/PVD,
sedentary lifestyle, sleep apnea, hyperlipidemia, DM, a-fib, carotid stenosis,
hypercoagulable state
Non-modifiable risk factors for stroke - ANSWER-age, gender, race, heredity,
another stroke
FAST screening tool - ANSWER-Face: symmetry, droop
Arm: equal movement, one sided weakenss, assess for drift (10 seconds), grip
strength, pull/push
Speech: do they make sense, confusion, able to form correct sentences
Time: Activate EMS
NIHSS Stroke Scale - ANSWER-a standardized assessment tool that helps to
evaluate the severity of stroke (0-42 with 42 being worst stroke ever)
Transient ischemic attack - ANSWER-temporary interruption in the blood supply to
the brain
Usually resolves naturally and lasts for 1-2 hours but can go up to 24 hours
Ischemic stroke - ANSWER-When we have a blockage in a blood vessel and it does
not allow us to perfuse tissues (87% of strokes)
Hemorrhagic stroke - ANSWER-When vessel ruptures and cannot get flow to the
area (area occurs from pressure and inability to supply blood)
s/s of right sided stroke - ANSWER-Paralysis with opposite side of body
Left sided field cut
Impulsive
Issues with perception
High fall risk
, S/s of left sided stroke - ANSWER-Paralysis with opposite side of body
Right sided field cut
Issues with language (r/e/g aphasia)
Delayed response
Easily frustrated with deficits
Cause of ischemic stroke - ANSWER-atherosclerosis, embolic clot shooting off from
somewhere else, HTN
Penumbra - ANSWER-Area that can be saved with intervention following a stroke
Most common site for ischemic strokes - ANSWER-MCA
what is unique about MCA based strokes - ANSWER-Usually do not effect legs, but
cause issues with sensation in face/arms
Basilar artery stroke can lead to what - ANSWER-locked in syndrome
Locked in syndrome - ANSWER-Individual is aware and capable of thinking but is
paralyzed and cannot communicate
Treatment for ischemic strokes - ANSWER-goal is to find out last known well
If within 3 hours you can use tPA to break up clot
outside of 3 hours and up to 24 hours you can be sent to neuro IR and have an
embolectomy/thrombectomy with cerebral angio gram
Within 6 hours of last known well you can have a cerebral angiogram and have intra
arterial tPA delivered rather than systemic
Nursing actions with ischemic strokes - ANSWER-Bed rest for 24 hours following
tPA due to bleeding risk, frequent neuro checks, avoid as much invasive procedures
as possible, get head Ct to check perfusion
Following an angiogram/thrombectomy they are a bleeding risk for their insertion
point, brain bleed, bedrest (flat initially depending on interventions), infection fo
insertion site, vitals, kidney function due to contrast (bun creatinine), distal perfusion
Contraindications of tPA - ANSWER-need to be above age 18, have a BP less than
180, recent surgeries, active bleeding, head trauma, recent falls, blood thinner use
How to lower BP prior to giving tPA - ANSWER-Labetalol initially and if still high give
nicardipine on continuous IV
labetalol/nicardipine SE - ANSWER-arrhythimas and hypotension
Hemorrhagic conversion - ANSWER-Secondary hemorrhagic stroke/injury during the
reperfusion period of an ischemic stroke
Causes of hemorrhagic stroke - ANSWER-HTN, aneurysm, AVM
Common location of hemorrhagic stroke - ANSWER-subarachnoid space
Answers
Lumbar puncture nursing management - ANSWER-lie flat for 2-6 hours afterward
Can bleed or get a very bad HA
Encourage to drink fluids
Monitor for increased temp which could progress to meningitis and difficulty voiding
Contraindications of Lumbar puncture - ANSWER-Increased ICP which can lead to
brainstem herniation
Ipsilateral - ANSWER-same side is effected
contralateral - ANSWER-opposite side is effected
Modifiable risk factors for stroke - ANSWER-Smoking, htn, obesity, CAD/PVD,
sedentary lifestyle, sleep apnea, hyperlipidemia, DM, a-fib, carotid stenosis,
hypercoagulable state
Non-modifiable risk factors for stroke - ANSWER-age, gender, race, heredity,
another stroke
FAST screening tool - ANSWER-Face: symmetry, droop
Arm: equal movement, one sided weakenss, assess for drift (10 seconds), grip
strength, pull/push
Speech: do they make sense, confusion, able to form correct sentences
Time: Activate EMS
NIHSS Stroke Scale - ANSWER-a standardized assessment tool that helps to
evaluate the severity of stroke (0-42 with 42 being worst stroke ever)
Transient ischemic attack - ANSWER-temporary interruption in the blood supply to
the brain
Usually resolves naturally and lasts for 1-2 hours but can go up to 24 hours
Ischemic stroke - ANSWER-When we have a blockage in a blood vessel and it does
not allow us to perfuse tissues (87% of strokes)
Hemorrhagic stroke - ANSWER-When vessel ruptures and cannot get flow to the
area (area occurs from pressure and inability to supply blood)
s/s of right sided stroke - ANSWER-Paralysis with opposite side of body
Left sided field cut
Impulsive
Issues with perception
High fall risk
, S/s of left sided stroke - ANSWER-Paralysis with opposite side of body
Right sided field cut
Issues with language (r/e/g aphasia)
Delayed response
Easily frustrated with deficits
Cause of ischemic stroke - ANSWER-atherosclerosis, embolic clot shooting off from
somewhere else, HTN
Penumbra - ANSWER-Area that can be saved with intervention following a stroke
Most common site for ischemic strokes - ANSWER-MCA
what is unique about MCA based strokes - ANSWER-Usually do not effect legs, but
cause issues with sensation in face/arms
Basilar artery stroke can lead to what - ANSWER-locked in syndrome
Locked in syndrome - ANSWER-Individual is aware and capable of thinking but is
paralyzed and cannot communicate
Treatment for ischemic strokes - ANSWER-goal is to find out last known well
If within 3 hours you can use tPA to break up clot
outside of 3 hours and up to 24 hours you can be sent to neuro IR and have an
embolectomy/thrombectomy with cerebral angio gram
Within 6 hours of last known well you can have a cerebral angiogram and have intra
arterial tPA delivered rather than systemic
Nursing actions with ischemic strokes - ANSWER-Bed rest for 24 hours following
tPA due to bleeding risk, frequent neuro checks, avoid as much invasive procedures
as possible, get head Ct to check perfusion
Following an angiogram/thrombectomy they are a bleeding risk for their insertion
point, brain bleed, bedrest (flat initially depending on interventions), infection fo
insertion site, vitals, kidney function due to contrast (bun creatinine), distal perfusion
Contraindications of tPA - ANSWER-need to be above age 18, have a BP less than
180, recent surgeries, active bleeding, head trauma, recent falls, blood thinner use
How to lower BP prior to giving tPA - ANSWER-Labetalol initially and if still high give
nicardipine on continuous IV
labetalol/nicardipine SE - ANSWER-arrhythimas and hypotension
Hemorrhagic conversion - ANSWER-Secondary hemorrhagic stroke/injury during the
reperfusion period of an ischemic stroke
Causes of hemorrhagic stroke - ANSWER-HTN, aneurysm, AVM
Common location of hemorrhagic stroke - ANSWER-subarachnoid space
