NURSING MED SURG 265 (STROKE) - WEEK 7 EAQ!!
What does the nurse recognize is the highest priority intervention for a patient
experiencing status epilepticus?
Answers :Diazepam IV
Rationale
Diazepam given in an IV push is one of the drugs of choice for a patient
experiencing status epilepticus. It is a rapid-acting benzodiazepine, but its action is
of short duration and so the drug must be followed with a longer-acting
anticonvulsant medication. Vecuronium is a paralyzing agent and is not used to
treat status epilepticus. Phenytoin is a long-acting anticonvulsant medication
commonly administered after a rapid-acting benzodiazepine (such as diazepam) to
help stop a seizure and prevent further seizures. A patient experiencing extended
episodes of status epilepticus may be at risk for dehydration, but Lactated Ringer's
IV fluids are not considered an immediate intervention.
p. 1378
Which action can the nurse delegate to the unlicensed assistive personnel (UAP) to
reduce fatigue for a patient recovering from a stroke at meal times?
Answers :Cut up the meat for the patient.
Rationale
The nurse should instruct the UAP to cut up the meat at meal times and to assist
with eating as needed. The ability to drink water during the meal may be limited if
the patient has problems swallowing, but this will not address fatigue. Placing the
head of the bed at 30 degrees is not high enough for eating and will not reduce
fatigue during the meal. Feeding this patient reduces independence and should be
avoided as the first action.
pp. 1360-1361
,The registered nurse is teaching a novice nurse about interventions for a patient
with a stroke on the left side of the brain. Which statement by the novice nurse
indicates a need for further teaching?
Answers :"I should refrain from distracting the patient during a sudden emotional
outburst."
Rationale
Distraction during emotional outbursts is important to help the patient overcome
the situation. A calm and relaxing environment should be maintained to prevent
any atypical behavior. Scolding during emotional outbursts should be avoided
because the patient is unable to control the feelings. After a stroke, it is important
to educate the patient and the family members about emotional outbursts.Test-
Taking Tip: Read the question carefully before looking at the answers: (1)
Determine what the question is really asking; look for key words; (2) Read each
answer thoroughly and see if it completely covers the material asked by the
question; (3) Narrow the choices by immediately eliminating answers you know
are incorrect.
pp. 1361-1362
A nurse is teaching a group of caregivers the warning signs of stroke. What type of
assessment data obtained from the patients should the nurse teach the caregivers to
consider as an emergency?
Answers :The patient suddenly has blurry vision.
The patient suddenly has slurred speech.
Rationale
Blood vessels carry blood throughout the body. When a blood vessel in the brain
becomes blocked for a short period of time, the blood flow to that area of the brain
slows or stops. This lack of blood (and oxygen) often leads to temporary symptoms
, such as slurred speech or blurry vision. Insomnia, deafness, and loss of appetite are
not associated with stroke.
p. 1346
What would be the appropriate nursing intervention for optimizing musculoskeletal
function of a patient with hemorrhagic stroke?
Answers :Discouraging pulling the patient's arm
Rationale
Shoulder displacement can occur if a patient's arm is pulled. Hemorrhagic stroke
may lead to joint contractures and muscular atrophy. Therefore it is important to
optimize musculoskeletal function. Lap boards prevent shoulder displacement, and
the patient should be instructed to use them. Trochanter rolls keep the patient's hip
in a neutral position and prevent external rotation. Posterior leg splints are advised
to the patient to prevent footdrop.
p. 1359
What rate should blood flow in the brain in order to maintain normal function?
Answers :55 mL/100 g
Rationale
Blood flow must be maintained at 55 mL/100 g for optimal brain functioning.
Blood flow of 15 mL/100 g or 25 mL/100 g is not sufficient for optimal brain
functioning. Blood flow of 70 mL/100 g indicates an increased rate.
p. 1346
A nurse is explaining methods to reduce the risk of stroke to a patient. What
instructions should the nurse convey to the patient?
Answers :C. Limit consumption of alcohol to moderate levels.
What does the nurse recognize is the highest priority intervention for a patient
experiencing status epilepticus?
Answers :Diazepam IV
Rationale
Diazepam given in an IV push is one of the drugs of choice for a patient
experiencing status epilepticus. It is a rapid-acting benzodiazepine, but its action is
of short duration and so the drug must be followed with a longer-acting
anticonvulsant medication. Vecuronium is a paralyzing agent and is not used to
treat status epilepticus. Phenytoin is a long-acting anticonvulsant medication
commonly administered after a rapid-acting benzodiazepine (such as diazepam) to
help stop a seizure and prevent further seizures. A patient experiencing extended
episodes of status epilepticus may be at risk for dehydration, but Lactated Ringer's
IV fluids are not considered an immediate intervention.
p. 1378
Which action can the nurse delegate to the unlicensed assistive personnel (UAP) to
reduce fatigue for a patient recovering from a stroke at meal times?
Answers :Cut up the meat for the patient.
Rationale
The nurse should instruct the UAP to cut up the meat at meal times and to assist
with eating as needed. The ability to drink water during the meal may be limited if
the patient has problems swallowing, but this will not address fatigue. Placing the
head of the bed at 30 degrees is not high enough for eating and will not reduce
fatigue during the meal. Feeding this patient reduces independence and should be
avoided as the first action.
pp. 1360-1361
,The registered nurse is teaching a novice nurse about interventions for a patient
with a stroke on the left side of the brain. Which statement by the novice nurse
indicates a need for further teaching?
Answers :"I should refrain from distracting the patient during a sudden emotional
outburst."
Rationale
Distraction during emotional outbursts is important to help the patient overcome
the situation. A calm and relaxing environment should be maintained to prevent
any atypical behavior. Scolding during emotional outbursts should be avoided
because the patient is unable to control the feelings. After a stroke, it is important
to educate the patient and the family members about emotional outbursts.Test-
Taking Tip: Read the question carefully before looking at the answers: (1)
Determine what the question is really asking; look for key words; (2) Read each
answer thoroughly and see if it completely covers the material asked by the
question; (3) Narrow the choices by immediately eliminating answers you know
are incorrect.
pp. 1361-1362
A nurse is teaching a group of caregivers the warning signs of stroke. What type of
assessment data obtained from the patients should the nurse teach the caregivers to
consider as an emergency?
Answers :The patient suddenly has blurry vision.
The patient suddenly has slurred speech.
Rationale
Blood vessels carry blood throughout the body. When a blood vessel in the brain
becomes blocked for a short period of time, the blood flow to that area of the brain
slows or stops. This lack of blood (and oxygen) often leads to temporary symptoms
, such as slurred speech or blurry vision. Insomnia, deafness, and loss of appetite are
not associated with stroke.
p. 1346
What would be the appropriate nursing intervention for optimizing musculoskeletal
function of a patient with hemorrhagic stroke?
Answers :Discouraging pulling the patient's arm
Rationale
Shoulder displacement can occur if a patient's arm is pulled. Hemorrhagic stroke
may lead to joint contractures and muscular atrophy. Therefore it is important to
optimize musculoskeletal function. Lap boards prevent shoulder displacement, and
the patient should be instructed to use them. Trochanter rolls keep the patient's hip
in a neutral position and prevent external rotation. Posterior leg splints are advised
to the patient to prevent footdrop.
p. 1359
What rate should blood flow in the brain in order to maintain normal function?
Answers :55 mL/100 g
Rationale
Blood flow must be maintained at 55 mL/100 g for optimal brain functioning.
Blood flow of 15 mL/100 g or 25 mL/100 g is not sufficient for optimal brain
functioning. Blood flow of 70 mL/100 g indicates an increased rate.
p. 1346
A nurse is explaining methods to reduce the risk of stroke to a patient. What
instructions should the nurse convey to the patient?
Answers :C. Limit consumption of alcohol to moderate levels.
