Brunner and Suddarth's Textbook of Medical Surgical Nursing; Chapter 67 Exam: Management of Patients with Cerebrovascular Disorders || With Questions & Answers (Graded A+)

Brunner and Suddarth's Textbook of Medical Surgical Nursing; Chapter 67 Exam: Management of Patients with Cerebrovascular Disorders || With Questions & Answers (Graded A+) Brunner and Suddarth's Textbook of Medical Surgical Nursing; Chapter 67 Exam: Management of Patients with Cerebrovascular Disorders || With Questions & Answers (Graded A+) A patient who just suffered a suspected ischemic stroke is brought to the ED by ambulance. On what should the nurse's primary assessment focus? - Cardiac and respiratory status -Seizure activity - Pain -Fluid and electrolyte balance - ANSWER - Cardiac and respiratory status Feedback: Acute care begins with managing ABCs. Patients may have difficulty keeping an open and clear airway secondary to decreased LOC. Neurologic assessment with close monitoring for signs of increased neurologic deficit and seizure activity occurs next. Fluid and electrolyte balance must be controlled carefully with the goal of adequate hydration to promote perfusion and decrease further brain activity. A patient with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this patient? -Rangeofmotion exercises to prevent contractures -Encouraging independence with ADLs to promote recovery -Early initiation of physical therapy -Absolute bed rest in a quiet, nonstimulating environment - ANSWER - Absolute bed rest in a quiet, nonstimulating environment Feedback: The patient is placed on immediate and absolute bed rest in a quiet, nonstressful environment because activity, pain, and anxiety elevate BP, which increases the risk for bleeding. Visitors are restricted. The nurse administers all personal care. The patient is fed and bathed to prevent any exertion that might raise BP. A patient recovering from a stroke has severe shoulder pain from subluxation of the shoulder and is being cared for on the unit. To prevent further injury and pain, the nurse caring for this patient is aware of what principle of care? -The patient should be fitted with a cast because use of a sling should be avoided due to adduction of the affected shoulder. -Elevation of the arm and hand can lead to further complications associated with edema. -Passively exercising the affected extremity is avoided in order to minimize pain. -The patient should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder