Chapter 57: Stroke Lewis:
Medical-Surgical Nursing, 10th Edition
A 63-yr-vintage affected person who began experiencing right arm and leg weak spot is
admitted to the emergency branch. In which order will the nurse put in force these actions
protected in the stroke protocol? (Put a comma and a area between each solution desire [A, B,
C, D].)
a. Obtain CT experiment with out evaluation.
B. Infuse tissue plasminogen activator (tPA).
C. Administer oxygen to maintain O2 saturation >ninety five%.
D. Use National Institute of Health Stroke Scale to evaluate patient. - ANS-ANS:
C, D, A, B
The initial movements have to be those who help with airway, breathing, and move. Baseline
neurologic exams ought to be achieved next. A CT test can be needed to rule out hemorrhagic
stroke earlier than tPA can be administered.
A 70-yr-antique lady patient with left-sided hemiparesis arrives through ambulance to the
emergency department. Which movement ought to the nurse take first?
A. Take the patient's blood strain.
B. Check the respiration fee and attempt.
C. Assess the Glasgow Coma Scale score.
D. Send the patient for a computed tomography (CT) test. - ANS-ANS: B
The initial nursing movement should be to evaluate the airway and take any wished movements
to ensure a patent airway. The different activities should take location quick after the ABCs
(airway, respiration, and move) are completed.
A lady patient who had a stroke 24 hours ago has expressive aphasia. An appropriate nursing
intervention to assist the patient communicate is to
a. Ask questions that the patient can solution with "yes" or "no."
b. Develop a list of phrases that the patient can read and exercise reciting.
C. Have the affected person practice her facial and tongue sporting events with a mirror.
D. Prevent embarrassing the affected person with the aid of answering for her if she does not
respond. - ANS-ANS: A
Communication will be facilitated and less irritating to the patient while questions that require a
"yes" or "no" response are used. When the language regions of the brain are injured, the
affected person might not be capable of examine or recite words, that allows you to frustrate the
patient without improving communication. Expressive aphasia is as a result of harm to the
language regions of the mind, not through the regions that manage the motor elements of
speech. The nurse need to allow time for the patient to respond.
A left-handed affected person with left-sided hemiplegia has trouble feeding himself. Which
intervention have to the nurse include in the plan of care?
, A. Provide a wide sort of meals picks.
B. Provide oral care before and after meals.
C. Assist the affected person to devour with the right hand.
D. Teach the affected person the "chin-tuck" technique. - ANS-ANS: C
Because the affected person has issue feeding himself, the ideal interventions will focus on
coaching the affected person to use the proper hand for self-feeding. The different interventions
are appropriate for patients with other etiologies for the imbalanced nutrients.
A male affected person who has proper-sided weakness after a stroke is making development in
mastering to use the left hand for feeding and different sports. The nurse observes that once the
patient's wife is visiting, she feeds and dresses him. Which nursing analysis is maximum
appropriate for the affected person?
A. Interrupted own family tactics related to results of contamination of a family member
b. Situational low vanity related to increasing dependence on partner for care
c. Disabled circle of relatives coping associated with insufficient knowledge by means of
affected person's partner
d. Impaired nutrients: less than frame requirements associated with hemiplegia and aphasia -
ANS-ANS: C
The information supports the analysis of disabled family coping because the wife does not
apprehend the rehabilitation software. There aren't any information helping low vanity, and the
affected person is making an attempt independence. The information do not help an interruption
in circle of relatives processes because this could be a standard pattern for the couple. There is
not any indication that the affected person has impaired nutrition.
A affected person admitted with possible stroke has been aphasic for 3 hours, and his
contemporary blood pressure (BP) is 174/94 mm Hg. Which order via the health care provider
need to the nurse query?
A. Keep head of bed increased at least 30 levels.
B. Infuse regular saline intravenously at 75 mL/hr.
C. Start a labetalol drip to keep BP much less than a hundred and forty/ninety mm Hg.
D. Administer tissue plasminogen activator (tPA) intravenously consistent with protocol. -
ANS-ANS: C
Because accelerated BP can be a protective response to keep cerebral perfusion,
antihypertensive remedy is usually recommended best if suggest arterial pressure (MAP) is
greater than130 mm Hg or systolic stress is extra than 220 mm Hg. Fluid intake should be 1500
to 2000 mL/day to hold cerebral blood glide. The head of the mattress need to be accelerated to
at least 30 tiers except the affected person has symptoms of terrible tissue perfusion. TPA may
be administered if the patient meets the alternative criteria for tPA use.
A affected person arrives within the emergency branch with hemiparesis and dysarthria that
started 2 hours previously, and fitness information display a history of numerous temporary
ischemic attacks (TIAs). The nurse anticipates making ready the patient for
a. Surgical endarterectomy.
B. Transluminal angioplasty.
C. Intravenous heparin drip management.
D. Tissue plasminogen activator (tPA) infusion. - ANS-ANS: D
Medical-Surgical Nursing, 10th Edition
A 63-yr-vintage affected person who began experiencing right arm and leg weak spot is
admitted to the emergency branch. In which order will the nurse put in force these actions
protected in the stroke protocol? (Put a comma and a area between each solution desire [A, B,
C, D].)
a. Obtain CT experiment with out evaluation.
B. Infuse tissue plasminogen activator (tPA).
C. Administer oxygen to maintain O2 saturation >ninety five%.
D. Use National Institute of Health Stroke Scale to evaluate patient. - ANS-ANS:
C, D, A, B
The initial movements have to be those who help with airway, breathing, and move. Baseline
neurologic exams ought to be achieved next. A CT test can be needed to rule out hemorrhagic
stroke earlier than tPA can be administered.
A 70-yr-antique lady patient with left-sided hemiparesis arrives through ambulance to the
emergency department. Which movement ought to the nurse take first?
A. Take the patient's blood strain.
B. Check the respiration fee and attempt.
C. Assess the Glasgow Coma Scale score.
D. Send the patient for a computed tomography (CT) test. - ANS-ANS: B
The initial nursing movement should be to evaluate the airway and take any wished movements
to ensure a patent airway. The different activities should take location quick after the ABCs
(airway, respiration, and move) are completed.
A lady patient who had a stroke 24 hours ago has expressive aphasia. An appropriate nursing
intervention to assist the patient communicate is to
a. Ask questions that the patient can solution with "yes" or "no."
b. Develop a list of phrases that the patient can read and exercise reciting.
C. Have the affected person practice her facial and tongue sporting events with a mirror.
D. Prevent embarrassing the affected person with the aid of answering for her if she does not
respond. - ANS-ANS: A
Communication will be facilitated and less irritating to the patient while questions that require a
"yes" or "no" response are used. When the language regions of the brain are injured, the
affected person might not be capable of examine or recite words, that allows you to frustrate the
patient without improving communication. Expressive aphasia is as a result of harm to the
language regions of the mind, not through the regions that manage the motor elements of
speech. The nurse need to allow time for the patient to respond.
A left-handed affected person with left-sided hemiplegia has trouble feeding himself. Which
intervention have to the nurse include in the plan of care?
, A. Provide a wide sort of meals picks.
B. Provide oral care before and after meals.
C. Assist the affected person to devour with the right hand.
D. Teach the affected person the "chin-tuck" technique. - ANS-ANS: C
Because the affected person has issue feeding himself, the ideal interventions will focus on
coaching the affected person to use the proper hand for self-feeding. The different interventions
are appropriate for patients with other etiologies for the imbalanced nutrients.
A male affected person who has proper-sided weakness after a stroke is making development in
mastering to use the left hand for feeding and different sports. The nurse observes that once the
patient's wife is visiting, she feeds and dresses him. Which nursing analysis is maximum
appropriate for the affected person?
A. Interrupted own family tactics related to results of contamination of a family member
b. Situational low vanity related to increasing dependence on partner for care
c. Disabled circle of relatives coping associated with insufficient knowledge by means of
affected person's partner
d. Impaired nutrients: less than frame requirements associated with hemiplegia and aphasia -
ANS-ANS: C
The information supports the analysis of disabled family coping because the wife does not
apprehend the rehabilitation software. There aren't any information helping low vanity, and the
affected person is making an attempt independence. The information do not help an interruption
in circle of relatives processes because this could be a standard pattern for the couple. There is
not any indication that the affected person has impaired nutrition.
A affected person admitted with possible stroke has been aphasic for 3 hours, and his
contemporary blood pressure (BP) is 174/94 mm Hg. Which order via the health care provider
need to the nurse query?
A. Keep head of bed increased at least 30 levels.
B. Infuse regular saline intravenously at 75 mL/hr.
C. Start a labetalol drip to keep BP much less than a hundred and forty/ninety mm Hg.
D. Administer tissue plasminogen activator (tPA) intravenously consistent with protocol. -
ANS-ANS: C
Because accelerated BP can be a protective response to keep cerebral perfusion,
antihypertensive remedy is usually recommended best if suggest arterial pressure (MAP) is
greater than130 mm Hg or systolic stress is extra than 220 mm Hg. Fluid intake should be 1500
to 2000 mL/day to hold cerebral blood glide. The head of the mattress need to be accelerated to
at least 30 tiers except the affected person has symptoms of terrible tissue perfusion. TPA may
be administered if the patient meets the alternative criteria for tPA use.
A affected person arrives within the emergency branch with hemiparesis and dysarthria that
started 2 hours previously, and fitness information display a history of numerous temporary
ischemic attacks (TIAs). The nurse anticipates making ready the patient for
a. Surgical endarterectomy.
B. Transluminal angioplasty.
C. Intravenous heparin drip management.
D. Tissue plasminogen activator (tPA) infusion. - ANS-ANS: D
