Exam (elaborations) HESI STROKE

HESI STROKE Which statement about transient ischemic at- tack (TM) is accurate? a. TIAs do not cause permanent brain damage. b. TIA increases the risk of stroke. c. Symptoms of a TIA usually resolve in 10- 15 minutes. d. After a TIA, a patient is prescribed a beta blocker. B The nurse is preparing to discharge a patient with transient ischemic attacks. What treatment areas does the nurse include in discharge teaching? (Select all that apply.) a. Reduction of high blood pressure b. Drug teaching for aspirin or another antiplatelet drug c. Lifestyle changes such as increased sleep and rest d. Controlling diabetes e. Increased risk for stroke Abde Which symptoms indicate that a patient's stroke has affected the right hemisphere? (select all that apply.) a. Loss of depth perception b. Aphasia c. Denies illness d. Cannot recognize faces e. Loss of hearing f. Depression Acde The nurse is performing a neurologic assessment on a patient with a suspected stroke. In addition to the level of consciousness (LOC), what is assessed to evaluate cognitive changes that may be occurring? (Select all that apply.) a. Denial of illness b. Proprioceptive dysfunction c. Presence of flaccid paralysis d. Impairment of memory e. Decreased ability to concentrate Abde Following a left hemisphere stroke, the patient has expressive (Broca's) aphasia. Which intervention is best to use when communicating with this patient? a. Repeat the names of objects on a routine basis. b. Face the patient and speak slowly and clearly. c. Obtain a whiteboard with an erasable marker. d. Develop a picture board that has objects and activities. D The nurse is caring for a patient with right hemisphere damage. The patient demonstrates disorientation to time and place, he has poor depth perception, and demonstrates neglect of the left visual field. Which task is best delegated to the unlicensed assistive personnel (UAP)? a. Move the patient's bed so that his affected side faces the door b. Teach the patient to wash both sides of his face c. Ensure a safe environment by removing clutter. d. Suggest to the family that they bring familiar family pictures C A patient with a right cerebral stroke may have safety issues related to which factor? a. Poor impulse control b. Alexia and agraphia c. Loss of language and analytical skills d. Slow and cautious behavior A A stroke patient is at risk for increased intracranial pressure (ICP) and is receiving oxygen 2 L via nasal cannula. The nurse is reviewing arterial blood gas (ABG) results. Which ABG value is of greatest concern for this patient? a. pH 7.32 b. Paco₂ of 60 mm Hg c. Pao₂ of 95 mm Hg d. HCO₃ of 28 mEq/L B Which statement is true about motor changes in a patient who has had a stroke? a. Motor deficit is ipsilateral to the hemisphere affected. b. Motor deficit is contralateral to the hemisphere affected. c. Bowel and bladder function remain intact. d. Flaccid paralysis is not an expected finding and should be reported promptly. B The preferred administration time for recombinant tissue plasminogen activator (rtPA [Retavase]) is within how long of stroke symptom onset? a. 30 to 60 minutes b. 3 to 4.5 hours c. 6 to 8 hours d. 24 to 30 hours B A priority problem for a patient who was admitted for a brain attack is the potential for aspiration. Which intervention is best to delegate to the UAP? a. Monitor the patient for and notify the charge nurse of any occurrence of coughing, choking, or difficulty breathing. b. Elevate the head of the bed as appropriate and slowly feed small spoonfuls of pudding, pausing between each spoonful. c. Assess the swallow reflex by placing the index finger and thumb on either side of the Adam's apple. d. Give the patient a class of water before feeding solid foods and have oral suction ready at the bedside. B A patient is diagnosed with an ischemic stroke. The UAP reports that the patient's Vital signs are blood pressure 150/ 100 mm Hg, pulse 78 beats/ min, respiratory rate of 20/ min, and temperature of 98.7° F. The patient's blood pressure is normally around 120/80. What action does the nurse take first? a. Report the blood pressure immediately to the physician because there is a danger of rebleeding. b. Ask the nursing assistant to repeat the blood pressure measurement in the other extremity with a manual cuff. c. Check the physician's orders to see if the blood pressure is within the acceptable parameters. d. Nothing; an elevated blood pressure is necessary for cerebral perfusion. C A patient with an ischemic stroke is placed on a cardiac monitor. Which cardiac dysrhythmia places the patient at risk for emboli? a. Sinus bradycardia b. Atrial fibrillation c. Sinus tachycardia d. First-degree heart block B The nurse is caring for a patient receiving medication therapy to prevent recurrence of stroke. Which medication is pharmacologically appropriate for this purpose? a. Enteric-coated aspirin (Ecotrin) b. Gabapentin (Neurontin) c. Recombinant tissue plasminogen activator (Retavase) d. Bevacizumab (Avastin) A A patient sustained a stroke that affected the right hemisphere of the brain. The patient has visual spatial deficits and deficits of proprioception. After assessing the safety of the patient's home, the home health nurse identifies which environmental feature that represents a potential safety problem for this patient? a. The handrail that borders the bathtub is on f the left-hand side. b. The patient's favorite chair faces the front door of the house. c. The patient's bedside table is on the right-hand side of the bed. d. Family has relocated the patient to a ground-floor bedroom. A A patient with a stroke is having some trouble swallowing. Which interventions does the nurse anticipate the speech-language pathologist to suggest after the swallowing evaluation is completed? (Select all that apply.) a. Position the patient upright while eating. b. Administer orange juice using a straw. c. Give small spoonfuls of soft foods such as custard. d. Add powdered thickeners to liquids. e. Provide liquid nutritional supplements between meals for added calories. Acde A patient presents to the emergency department with signs and symptoms of an ischemic stroke. What is the priority factor when considering fibrinolytic therapy? a. Age older than 80 years b. History of stroke c. Recent surgery d. Time since onset of symptoms D A patient received rtPA for the treatment of ischemic stroke and the physician ordered an IV sodium heparin infusion. In relation to the drug therapy, what does the nurse monitor for? a. Elevated prothrombin level b. Bleeding gums or bruising c. Nausea and vomiting d. Elevated hematocrit or hemoglobin B The nurse notices that a patient seems to be having trouble swallowing. Which intervention does the nurse employ for this patient? a. Limit the diet to clear liquids given through a straw. b. Keep the patient on NPO status until swallowing is assessed. c. Monitor the patient's weight and compare to baseline. d. Sit with the patient while the patient eats and observe for swallowing difficulties. B A male patient has sustained a stroke and the nurse is planning interventions to help him reestablish urinary continence. What action does the nurse take? a. Obtain an order for a Foley catheter. b. Offer the urinal to the patient every 6 hours. c. Check postvoid residual urine with a bladder ultrasound. d. Restrict fluid to 1500 mL/day. C A patient with increased ICP is to receive IV mannitol (Osmitrol). Which nursing actions are taken concerning this drug? (Select all that apply.) a. Draw up the drug through a filtered needle. b. Insert a Foley catheter for strict measurement of urine output. c. Monitor serum and urine osmolality on a weekly basis. d. Assess for acute renal failure, weakness, or edema. e. Administer mannitol through a filter in the IV tubing. f. Administer furosemide (Lasix) as an adjunctive therapy. Abdef The nurse is talking to the family of a stroke patient about home care measures. Which topics does the nurse include in this discussion? (select all that apply) a. Need for caregivers to plan for routine respite care and protection of own health b. Evaluation for potential safety risks such as throw rugs or slippery floors c. Awareness of potential patient frustration associated with communication d. Avoidance of independent transfers by the patient because of safety issues e. Access to health resources such as publications from the American Heart Association f. Referral to hospice and encouragement of family discussion of advance directives. Abce Which patients are at increased risk for stroke? (Select all that apply.) a. 66-year-old man with diabetes mellitus b. 35-year-old healthy woman who uses oral contraceptives c. 47-year -old woman who exercises regularly d. 35-year-old man with history of multiple transient ischemic attacks e. 25-year-old woman with Bell's palsy f. 53-year-old man with chronic alcoholism Abdf A patient displays signs of increased ICP, confusion, slurred speech, and unilateral weakness in the upper extremity. Which diagnostic test for this patient does the nurse question? a. Lumbar puncture (LP) b. Computed tomography (CT) c. Positron emission tomography (PET) d. Magnetic resonance imaging (MRI) A Which interventions does the nurse use for a patient with a left hemisphere stroke? (Select all that apply.) a. Teach the patient to wash both sides of the face. b. Place pictures and familiar objects around the patient. c. Reorient the patient frequently. d. Repeat names of commonly used objects. e. Approach the patient from the unaffected side. f. Establish a structured routine for the patient Bcdf The nurse has completed teaching a patient about carotid artery angioplasty with stenting (CAS). Which statement by the patient indicates understanding of the purpose of the procedure? a. "The stent opens the blockage enough to establish blood flow" b. "The stent occludes the abnormal artery to prevent bleeding." c. "The stent bypasses the blockage." d. "The stent catches any clot debris." A The nurse is caring for a patient with an ischemic stroke. Which position is the patient placed in according to current nursing practice? a. Head of the bed is elevated 25 to 30 degrees b. Head of the bed is elevated to 45 degrees c. Supine with hips in flexed position d. The best head of bed position has not been determined D The nurse is caring for a patient at risk for an increased ICP related to ischemic stroke. For what purpose does the nurse place the patient's head in a midline neutral position? a. Provide comfort for the patient b. Protect the cervical spine c. Facilitate venous drainage from brain d. Decrease pressure from cerebrospinal fluid C In planning care for a patient with increased ICP, what does the nurse do to minimize ICP? a. Gives the bath, changes the linens, and does passive ROM exercises to hands/fingers then allows the patient to rest b. Gives the bath, allows the patient to rest, changes the linens, allows the patient to rest, and then performs passive ROM exercises to hands/fingers c. Defers the bath, changes the linens, and does passive ROM exercises to extremities until the danger of increased ICP as passed. d. Contacts the physician for specific orders about all activities related to the care of the patient that might cause increased ICP. B The nurse is caring for a patient at risk for increased ICP. Which sign is most likely to be the first indication of increased ICP? a. Decline of level of consciousness b. Increase in systolic blood pressure c. Change in pupil size and response d. Abnormal posturing of extremities A The stroke patient is prescribed docusate (Colace) once a day in the morning. What is the purpose of this drug specific to this patient? a. Laxative to prevent constipation b. Soften the patient's stool c. Increase fluid content of stool d. Prevent increased ICP D Which type of hematoma occurs between the skull and the dura? a. Epidural hematoma b. Subdural hematoma c. Intracranial hemorrhage d. Contusion A The nurse is caring for a patient admitted with the medical diagnosis of probably epidural hematoma and decreased level of consciousness. During the shift, the patient becomes lucid and is alert and talking. The family reports this is her baseline mental status. What is the nurse's next action? a. Stay with the patient and have the charge nurse alert the physician because this is an ominous sign for the patient. b. Document the patient's exact behaviors, compare to previous nursing entries, and continue the neurologic assessments every 2 hours. c. Point out to the family that the dangerous period has passed, but encourage them to leave so the patient does not become overly fatigued. d. Monitor the patient for the next 48 hours to 2 weeks because a subacute condition may be slowly developing. A Blood flow to the brain remains fairly constant as a result of which process? a. Autostasis b. Automobilization c. Hemodynamic stasis d. Autoregulation D A patient has been diagnosed with a large lesion of the parietal lobe and demonstrates loss of sensory function. Which nursing intervention is applicable for this patient? a. Play music for the patient for at least 30 minutes each day. b. Teach the patient to test the water temperature used for bathing c. Position the patient reclining in bed or in a chair for meals d. Use a picture of the patient's spouse and ask the patient to state the spouse's name. B Which description best defines a basilar skull fracture? a. A simple, clean break in the skull b. A direct opening to brain tissue c. Fragments of bone are in brain tissue d. Cerebrospinal fluid leaks from nose or ears D Which determination must be made first in assessing a patient with traumatic brain injury? a. Presence of spinal injury b. Whether the patient is hypotensive c. Presence of a patent airway d. Level of consciousness using the Glasgow coma scale C Which statement is true about a patient at risk for increased ICP? a. The appearance of abnormal posturing occurs only when the patient is not positioned for comfort. b. Cushing's reflex, an early sign of increased ICP, consists of severe hypertension, wideing pulse pressure, and bradycardia. c. Dilated or pinpoint pupils that are slow to react to light or nonreactive to light are signs of increased ICP. d. Areas of tenderness over the scalp indicate the presence of contrecoup injuries. C A patient has sustained a traumatic brain injury. Which nursing intervention is best for this patient? a. Assess vital signs every 8 hours b. Position to avoid extreme flexion c. Increase fluid intake for the first 48 hours d. Administer glucocorticoids B The nurse is caring for a patient with a relatively minor head injury after a bump to the head. The nurse has the greatest concern about which symptom? a. Headache b. Nausea and vomiting c. Unequal pupils d. Dizziness C The patient with a traumatic brain injury is receiving mechanical ventilation. Why does the health care provider adjust ventilator settings to maintain a partial pressure of arterial carbon dioxide (Paco₂) at 35 to 28 mm Hg? a. Lower levels of arterial carbon dioxide are essential for gas exchange b. Carbon dioxide is a potent vasodilator that can cause increased ICP c. Carbon dioxide is a waste product that must be eliminated from the body d. Lower levels of arterial carbon dioxide facilitate brain oxygenation B Which statement is true about respiratory problems in a patient with a major head injury? a. Atelectasis and pneumonia can be prevented by proper pulmonary hygiene b. Suctioning should be avoided because of the increase in ICP c. Neurologic pulmonary edema occurs frequently d. The patient should avoid breathing deeply because of increased ICP A Which Glasgow coma scale (GCS) data set indicates the most severe injury and loss of consciousness? a. GCS of 13 with loss of consciousness of 15 minutes b. GCS of 9 with loss of consciousness of 30 minutes c. GCS of 12 with loss of consciousness of 3 hours d. GCS of 8 with loss of consciousness of 6.5 hours D The nurse is assessing a patient who was struck in the head several times with a bat. There is clear fluid that appears to be leaking from the nose. What action does the nurse take? a. Hand the patient a tissue and ask him to gently blow the nose; observe the nasal discharge for blood clots. b. Immediately report the finding to the physician and document the observation in the nursing notes c. Place a drop of the fluid on a white absorbent background and look for a yellow halo d. Allow the patient to wipe his nose, but no other action is needed; he has most likely been crying C Which statement is true for a patient with a basilar skull fracture? a. There is potential for hemorrhage caused by damage to the internal carotid artery. b. There is an increased risk for loss of functioning abilities such as toileting c. There is an increased risk for cytotoxic or cellular edema with loss of consciousness. d. There is potential for decorticate or decerebrate posturing with loss of motor function. A A patient is admitted for a closed head injury from a fall down the stairs. The patient has no history of respiratory disease and no apparent respiratory distress. However, the physician orders oxygen 2 L via nasal cannula. What is the nurse's best action? a. Check the pulse oximetry and apply the oxygen if the saturation level drops below 90% b. Call the physician to discontinue the order because it is unnecessary c. Deliver the oxygen as ordered because hypoxemia may precipitate increased ICP d. Apply the nasal cannula as ordered and gradually wean the patient off the oxygen when the LOC improves C The nurse is conducting a presentation to a group of students on the prevention of head injuries. Which statement by a student indicates a need for additional teaching? a. "Drinking, driving, and speeding contribute to the risk for injury" b. "Males are more likely to sustain head injury compared to females." c. "Young people are less likely to get injured because of faster reflexes" d. "Following game rules and not goofing around can prevent injuries" C The nurse is taking a history on a teenager who was involved in a motor vehicle accident with friends. The patient has an obvious contusion of the forehead, seems confused, and is laughing loudly and yelling "Ruby! Ruby!" What is the best question for the nurse to ask the patient's friends? a. "Where and why did the accident occur?" b. How can we notify the family for consent for treatment?" c. "Was the patient using drugs or alcohol prior to the accident?" d. "Who is Ruby and why is the patient calling for her?" C The provider has prescribed barbiturate coma therapy for a patient with increased ICP. Which complication does the nurse monitor for? a. Decreased LOC b. Reduced gastric motility c. Decreased respiratory rate d. Reduced Glasgow coma scale score B The nurse is performing discharge teaching for the family and patient who has had prolonged hospitalization and rehabilitation therapy for severe craniocerebral trauma after a motor-cycle accident. What elements of instruction does the nurse include? (select all that apply) a. Review seizure precautions b. Stimulate the patient with frequent changes in the environment c. Develop a routine of activities with consistency and structure. d. Attend follow-up appointments with therapists e. Encourage the family to seek respite care if needed. f. Encourage the patient to wear a helmet when riding Acde A patient has sustained a major head injury and the nurse is assessing the patient's neurologic status every 2 hours. What early sign of increased ICP does the nurse monitor for? a. Change in the LOC b. Cheyne-Stokes respirations c. Severe hypertension with widened pulse pressure (Cushing's reflex) d. Dilated and nonreactive pupils A The nurse is giving a discharge instructions to the mother of a child who bumped her head on a table. Which statement by the mother indicates an understanding of instructions? a. "I should not let her fall asleep" b. She may have nausea or headache for the first 24 hours" c. "She should gently blow her nose and I'll observe for bleeding" d. "She can run and play as she usually does" B The nurse is caring for an intubated patient with increased ICP. If the patient needs to be suctioned, which nursing action does the nurse take to avoid further aggravating the increased ICP? a. Manually hyperventilate with 100% oxygen before passing the catheter b. Maintain strict sterile technique when performing endotracheal suctioning c. Perform oral suctioning frequently, but do not perform endotracheal suctioning d. Obtain an order for an arterial blood gas before suctioning the patient A A patient is scheduled for a craniotomy. What does the nurse tell the patient and family about the procedure? a. The head will not need to be shaved at the surgical site. b. There is a coma state for up to several days after surgery. c. Drainage of a small to moderate amount of cerebrospinal fluid after surgery is normal. d. The family will need to remind the patient of their names and relationships. C A patient who had a craniotomy develops the postoperative complication of syndrome of inappropriate antidiuretic hormone(SIADH). The patient's sodium level is 126 mEq/L and the serum osmolality is decreased. In light of this development, which physician order does the nurse question? a. Encourage oral fluids b. Normal saline IV at 150Ml/hr c. Strict intake and output d. Daily weights A Which statement is true about increased ICP in a surgical patient? a. It is a minor postoperative complication b. Diuretics such as furosemide may be given to decrease it. c. Cerebral edema usually subsides within 72 hours d. If not contraindicated, the head of the bed should be placed at 30 degrees D The nurse who is providing postoperative care for a patient who had a craniotomy immediately notifies the surgeon of which assessment finding? a. Drainage in the Jackson-Pratt container of 45 mL/8 hours b. Intracranial pressure of 15 mm Hg c. Pco₂ level of 35 mm Hg d. Serum sodium of 117 mEq/L D Which modifiable risk factors for stroke would be most important for the nurse to include when planning a community education program? A. Hypertension B. Hyerlipidemia C. Alcohol consumption D. Oral contraceptive use A. Hypertension Hypertension is the single most important modifiable risk factor, but it is still often undetected and inadequately treated. The public is often more aware of hyperlipidemia and oral contraceptive use as risk factors for stroke. Alcohol is also a modifiable risk factor. The nurse would expect to find what clinical manifestation in a patient admitted with a left-sided stroke? A. Impulsivity B. Impaired speech C. Left-side neglect D. Short attention span B. Impaired speech Clinical manifestations of left-sided brain damage include right hemiplegia, impaired speech/language, impaired right/left discrimination, and slow and cautious performance. Impulsivity, left-sided neglect, and short attention span are all manifestations of right-sided brain damage. The nurse is discharging a patient admitted with a transient ischemic attack (TIA). For which medications might the nurse expect to provide discharge instructions (select all that apply)? A. Clopidogrel (Plavix) B. Enoxaparin (Lovenox) C. Dipyridamole (Persantine) D. Enteric-coated aspirin (Ecotrin) E. Tissue plasminogen activator (tPA) A. Clopidogrel (Plavix) C. Dipyridamole (Persantine) D. Enteric-coated aspirin (Ecotrin) Aspirin is the most frequently used antiplatelet agent. Other drugs to prevent clot formation include clopidogrel (Plavix), dipyridamole (Persantine), ticlopidine (Ticlid), combined dipyridamole and aspirin (Aggrenox), and anticoagulant drugs, such as oral warfarin (Coumadin). Tissue plasminogen activator is a fibrinolytic medication used to treat ischemic stroke not prevent TIAs or strokes. Which intervention is most appropriate when communicating with a patient suffering from aphasia following a stroke? A. Present several thoughts at once so that the patient can connect the ideas. B. Ask open-ended questions to provide the patient the opportunity to speak. C. Finish the patient's sentences to minimize frustration associated with slow speech. D. Use simple, short sentences accompanied by visual cues to enhance comprehension. D. Use simple, short sentences accompanied by visual cues to enhance comprehension. When communicating with a patient with aphasia, the nurse should present one thought or idea at a time. Ask questions that can be answered with a "yes," "no," or simple word. Use visual cues and allow time for the individual to comprehend and respond to conversation. Computed tomography (CT) of a 68-year-old male patient's head reveals that he has experienced a hemorrhagic stroke. What is the priority nursing intervention in the emergency department? A. Maintenance of patient's airway. B. Positioning to promote cerebral perfusion. C. Control of fluid and electrolyte imbalances. D. Administration of tissue plasminogen activator (tPA) A. Maintenance of patient's airway. Maintenance of a patent airway is the priority in the acute care of a patient with a hemorrhagic stroke. It supersedes the importance of fluid and electrolyte imbalance and positioning. tPA is contraindicated in hemorrhagic stroke. A female patient has left-sided hemiplegia following an ischemic stroke that she experienced 4 days earlier. How should the nurse best promote the health of the patient's integumentary system? A. Position the patient on her weak side the majority of the time. B. Alternate the patient's positioning between supine and side-lying. C. Avoid the use of pillows in order to promote independence in positioning. D. Establish a schedule for the message of areas where skin breakdown emerges. B. Alternate the patient's positioning between supine and side-lying. A position change schedule should be established for stroke patients. An example is side-back-side, with a maximum duration of 2 hours for any position. The patient should be positioned on the weak or paralyzed side for only 30 minutes. Pillows may be used to facilitate positioning. Areas of skin breakdown should never be massaged. Which sensory-perceptual deficit is associated with left-sided stroke (right hemiplegia)? A. Overestimation of physical abilities. B. Difficulty judging position and distance. C. Slow and possibly fearful performance of tasks. D. Impulsivity and impatience at performing tasks. C. Slow and possibly fearful performance of tasks. Patients with a left-sided stroke (right hemiplegia) commonly are slower in organization and performance of tasks and may have a fearful, anxious response to a stroke. Overconfidence, spatial disorientation, and impulsivity are more commonly associated with a right-sided stroke. The female patient has been brought to the ED with a sudden onset of a severe headache that is different from any other headache she has had previously. When considering the possibility of a stroke, which type of stroke should the nurse know is most likely occurring? A. TIA B. Embolic stroke C. Thrombotic stroke D. Subarachnoid hemorrhage D. Subarachnoid hemorrhage Headache is common in a patient who has a subarachnoid hemorrhage or an intracerebral hemorrhage. A TIA is a transient loss of neurologic function usually without a headache. A headache may occur with an ischemic embolic stroke, but severe neurologic deficits are the initial symptoms. The ischemic thrombotic stroke manifestations progress in the first 72 hours as infarction and cerebral edema increase. The patient with diabetes mellitus has had a right-sided stroke. Which nursing intervention should the nurse plan to provide for this patient related to expected manifestations of this stroke? A. Safety measures B. Patience with communication C. Mobility assistance on the right side D. Place food in the left side of patient's mouth A. Safety measures A patient with a right-sided stroke has spatial-perceptual deficits, tends to minimize problems, has a short attention span, is impulsive, and may have impaired judgment. Safety is the biggest concern for this patient. Hemiplegia occurs on the left side of this patient's body. The patient with a left-sided stroke has hemiplegia on the right, is more likely to have communication problems, and needs mobility assistance on the right side with food placed on the left side if the patient needs to be fed after a swallow evaluation has taken place. The nurse is planning psychosocial support for the patient and family of the patient who suffered a stroke. What factor will most likely have the greatest impact on positive family coping with the situation? A. Specific patient neurologic deficits B. The patient's ability to communicate C. Rehabilitation potential of the patient D. Presence of complications of a stroke C. Rehabilitation potential of the patient Although a patient's neurologic deficit might initially be severe after a stroke, the ability of the patient to recover is most likely to positively impact the family's coping with the situation. Providing explanations and emotional support beginning in the acute phase through the rehabilitation phase will facilitate coping. Emphasizing successes will offer the most realistic hope for the patient's rehabilitation and helps maintain hope for the patient's future abilities. The nurse in a primary care provider's office is assessing several patients today. Which patient is most at risk for a stroke? A. A 92-year-old female who takes warfarin (Coumadin) for atrial fibrillation. B. A 28-year-old male who uses marijuana after chemotherapy to control nausea. C. A 42-year-old female who takes oral contraceptives and has migraine headaches. D. A 72-year-old male who has hypertension and diabetes mellitus and smokes tobacco. D. A 72-year-old male who has hypertension and diabetes mellitus and smokes tobacco. Stroke risk increases after 65 years of age. Strokes are more common in men. Hypertension is the single most important modifiable risk factor for stroke. Diabetes mellitus is a significant stroke risk factor; and smoking nearly doubles the risk of a stroke. Other risk factors include drug abuse (especially cocaine), high-dose oral contraception use, migraine headaches, and untreated heart disease such as atrial fibrillation. The nurse is teaching a senior citizen's group about signs and symptoms of a stroke. Which statement by the nurse would provide accurate information? A. "Take the person to the hospital if a headache lasts for more than 24 hours." B. "Stroke symptoms usually start when the person is awake and physically active." C. "A person with a transient ischemic attack has mild symptoms that will go away." D. "Call 911 immediately if a person develops slurred speech or difficulty speaking." D. "Call 911 immediately if a person develops slurred speech or difficulty speaking." Medical assistance should be obtained immediately for someone with signs and symptoms of a stroke such as sudden numbness; weakness; paralysis of the face, arm, or leg (especially on one side of the body); sudden confusion; trouble speaking or understanding; slurred speech; sudden trouble seeing in one or both eyes; sudden trouble walking; dizziness; loss of balance or coordination; or a sudden, severe headache with no known cause. A person with signs and symptoms of a transient ischemic attack should seek medical attention immediately because it is unknown if the symptoms will resolve or persist and progress to a stroke. Onset of signs and symptoms of a stroke vary depending on the type. Onset of an ischemic thrombotic stroke usually occurs at rest. Onset of an ischemic embolic stroke is not related to rest or activity, and onset of a hemorrhagic stroke usually occurs with activity. The physician orders alteplase (Activase) for a 58-year-old man diagnosed with an acute ischemic stroke. Which nursing action is most appropriate? A. Administer the medication by an IV route at 15 mL/hr for 24 hours. B. Insert two or three large-bore IV catheters before administering the medication. C. If gingival bleeding occurs, discontinue the medication and notify the physician. D. Reduce the medication infusion rate for a systolic blood pressure above 180 mm Hg. B. Insert two or three large-bore IV catheters before administering the medication. Before giving alteplase, the nurse should start two or three large bore IVs. Bleeding is a major complication with fibrinolytic therapy, and venipunctures should not be attempted after alteplase is administered. Altepase is administered IV with an initial bolus dose followed by an infusion of the remaining medication within the next 60 minutes. Gingival bleeding is a minor complication and may be controlled with pressure or ice packs. Control of blood pressure is critical prior to altepase administration and for the following 24 hours. Before administering altepase, a systolic pressure above 180 mm Hg or diastolic pressure above 110 mm Hg requires aggressive blood pressure treatment to reduce the risk of cerebral hemorrhage. The nurse observes a student nurse assigned to initiate oral feedings for a 68-year-old woman with an ischemic stroke. The nurse should intervene if she observes the student nurse: A. giving the patient 8 ounces of ice water to swallow. B. telling the patient to perform a chin tuck before swallowing. C. assisting the patient to sit in a chair before feeding the patient. D. assessing cranial nerves IX and X before the patient attempts to eat. A. giving the patient 8 ounces of ice water to swallow. The majority of patients after a stroke have dysphagia. The gag reflex and swallowing ability (cranial nerves IX and X) should be assessed before the first oral feeding. To assess swallowing ability, the nurse should elevate the head of the bed to an upright position (unless contraindicated) and give the patient a very small amount (not 8 ounces) of crushed ice or ice water to swallow. The patient should remain in a high Fowler's position, preferably in a chair with the head flexed forward, for the feeding and for 30 minutes following. A 74-year-old man who has right-sided extremity paralysis related to a thrombotic stroke develops constipation. Which action should the nurse take first? A. Assist the patient to the bathroom every 2 hours. B. Provide incontinence briefs to wear during the day. C. Administer a bisocodyl (Dulcolax) rectal suppository every day. D. Arrange for several servings per day of cooked fruits and vegetables. D. Arrange for several servings per day of cooked fruits and vegetables. Patients after a stroke frequently have constipation. Dietary management includes the following: fluid intake of 2500 to 3000 mL daily, prune juice (120 mL) or stewed prunes daily, cooked fruit three times daily, cooked vegetables three times daily, and whole-grain cereal or bread three to five times daily. Patients with urinary incontinence should be assisted to the bathroom every 2 hours when appropriate. Suppositories may be ordered for short-term management if the patient does not respond to increased fluid and fiber. Incontinence briefs are indicated as a short-term intervention for urinary incontinence. Of the following patients, the nurse recognizes that the one with the highest risk for stroke is a(n): A. obese 45-year old Native American. B. 35-year-old Asian American woman who smokes. C. 32-year-old white woman taking oral contraceptives. D. 65-year-old African American man with hypertension. D. 65-year-old African American man with hypertension. Nonmodifiable risk factors for stroke include age (older than 65 years), male gender, ethnicity or race (incidence is highest in African Americans; next highest in Hispanics, Native Americans/Alaska Natives, and Asian Americans; and next highest in white people), and family history of stroke or personal history of a transient ischemic attack or stroke. Modifiable risk factors for stroke include hypertension (most important), heart disease (especially atrial fibrillation), smoking, excessive alcohol consumption (causes hypertension), abdominal obesity, sleep apnea, metabolic syndrome, lack of physical exercise, poor diet (high in saturated fat and low in fruits and vegetables), and drug abuse (especially cocaine). Other risk factors for stroke include a diagnosis of diabetes mellitus, increased serum levels of cholesterol, birth control pills (high levels of progestin and estrogen), history of migraine headaches, inflammatory conditions, hyperhomocystinemia, and sickle cell disease. Of the following patients, the nurse recognizes that the one with the highest risk for a stroke is a(n) a. obese 45-year-old Native American. b. 35-year-old Asian American woman who smokes. c. 32-year-old white woman taking oral contraceptives. d. 65-year-old African American man with hypertension. d Rationale: Nonmodifiable risk factors for stroke include age (older than 65 years), male gender, ethnicity or race (incidence is highest in African Americans; next highest in Hispanics, Native Americans/Alaska Natives, and Asian Americans; and next highest in white people), and family history of stroke or personal history of a transient ischemic attack or stroke. Modifiable risk factors for stroke include hypertension (most important), heart disease (especially atrial fibrillation), smoking, excessive alcohol consumption (causes hypertension), abdominal obesity, sleep apnea, metabolic syndrome, lack of physical exercise, poor diet (high in saturated fat and low in fruits and vegetables), and drug abuse (especially cocaine). Other risk factors for stroke include a diagnosis of diabetes mellitus, increased serum levels of cholesterol, birth control pills (high levels of progestin and estrogen), history of migraine headaches, inflammatory conditions, hyperhomocystinemia, and sickle cell disease. The factor related to cerebral blood flow that most often determines the extent of cerebral damage from a stroke is the a. amount of cardiac output. b. oxygen content of the blood. c. degree of collateral circulation. d. level of carbon dioxide in the blood. c Rationale: The extent of the stroke depends on the rapidity of onset, size of the lesion, and presence of collateral circulation. Information provided by the patient that would help differentiate a hemorrhagic stroke from a thrombotic stroke includes a. sensory disturbance. b. a history of hypertension. c. presence of motor weakness. d. sudden onset of severe headache. d Rationale: A hemorrhagic stroke usually causes a sudden onset of symptoms, which include neurologic deficits, headache, nausea, vomiting, decreased level of consciousness, and hypertension. Ischemic stroke symptoms may progress in the first 72 hours as infarction and cerebral edema increase. A patient with right-sided hemiplegia and aphasia resulting from a stroke most likely has involvement of the a. brainstem. b. vertebral artery. c. left middle cerebral artery. d. right middle cerebral artery. c Rationale: If the middle cerebral artery is involved in a stroke, the expected clinical manifestations include aphasia, motor and sensory deficit, and hemianopsia on the dominant side and include neglect, motor and sensory deficit, and hemianopsia on the nondominant side. The nurse explains to the patient with a stroke who is scheduled for angiography that this test is used to determine the a. presence of increased ICP. b. site and size of the infarction. c. patency of the cerebral blood vessels. d. presence of blood in the cerebrospinal fluid. c Rationale: Angiography provides visualization of cerebral blood vessels and can help estimate perfusion and detect filling defects in the cerebral arteries. A patient experiencing TIAs is scheduled for a carotid endarterectomy. The nurse explains that this procedure is done to a. decrease cerebral edema. b. reduce the brain damage that occurs during a stroke in evolution. c. prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow. d. provide a circulatory bypass around thrombotic plaques obstructing cranial circulation. c Rationale: In a carotid endarterectomy, the atheromatous lesion is removed from the carotid artery to improve blood flow. For a patient who is suspected of having a stroke, one of the most important pieces of information that the nurse can obtain is a. time of the patient's last meal. b. time at which stroke symptoms first appeared. c. patient's hypertension history and management. d. family history of stroke and other cardiovascular diseases. b Rationale: During initial evaluation, the most important point in the patient's history is the time since onset of stroke symptoms. If the stroke is ischemic, recombinant tissue plasminogen activator (tPA) must be administered within 3 to 4.5 hours of the onset of clinical signs of ischemic stroke; tPA reestablishes blood flow through a blocked artery and prevents brain cell death in patients with acute onset of ischemic stroke. Bladder training in a male patient who has urinary incontinence after a stroke includes a. limiting fluid intake. b. keeping a urinal in place at all times. c. assisting the patient to stand to void. d. catheterizing the patient every 4 hours. c Rationale: In the acute stage of stroke, the primary urinary problem is poor bladder control and incontinence. Nurses should promote normal bladder function and avoid the use of indwelling catheters. A bladder retraining program consists of (1) adequate fluid intake, with most fluids administered between 7:00 am and 7:00 pm; (2) scheduled toileting every 2 hours with the use of a bedpan, commode, or bathroom; and (3) noting signs of restlessness, which may indicate the need for urination. Intermittent catheterization may be used for urinary retention (not urinary incontinence). During the rehabilitation phase after a stroke, nursing interventions focused on urinary continence include (1) assessment for bladder distention by palpation; (2) offering the bedpan, urinal, commode, or toilet every 2 hours during waking hours and every 3 to 4 hours at night; (3) using a direct command to help the patient focus on the need to urinate; (4) assistance with clothing and mobility; (5) scheduling most fluid intake between 7:00 am and 7:00 pm; and (6) encouraging the usual position for urinating (i.e., standing for men and sitting for women). Common psychosocial reactions of the stroke patient to the stroke include (select all that apply) a. depression. b. disassociation. c. intellectualization. d. sleep disturbances. e. denial of severity of stroke. a, d, e Rationale: The patient with a stroke may experience many losses, including sensory, intellectual, communicative, functional, role behavior, emotional, social, and vocational losses. Some patients experience long-term depression, manifesting symptoms such as anxiety, weight loss, fatigue, poor appetite, and sleep disturbances. The time and energy required to perform previously simple tasks can result in anger and frustration. Frustration and depression are common in the first year after a stroke. A stroke is usually a sudden, extremely stressful event for the patient, caregiver, family, and significant others. The family is often affected emotionally, socially, and financially as their roles and responsibilities change. Reactions vary considerably but may involve fear, apprehension, denial of the severity of stroke, depression, anger, and sorrow. aneurysms congenital or acquired weakness of the arterial wall resulting in dilation and ballooning of the vessel aphasia an abnormal neurologic condition in which language function is disordered or absent because of an injury to certain areas of the cerebral cortex brain attack term used to describe a stroke; communicates the urgency of recognizing the clinical manifestations of a stroke and treating a medical emergency cerebrovascular accident (CVA) term used to describe a stroke dysarthria a disturbance in the muscular control of speech, resulting from interference in the control and execution over the muscles of speech, usually caused by damage to a central or peripheral motor nerve dysphasia difficulty related to the comprehension or use of language embolic stroke a stroke that occurs when an embolus lodges in and occludes a cerebral artery, resulting in infarction and edema of the area supplied by the involved vessel hemorrhagic stroke a stroke that results from bleeding into the brain tissue itself (intracerebral or intraparenchymal hemorrhage) or into the subarachnoid space or ventricles (subarachnoid hemorrhage or intraventricular hemorrhage) intracerebral hemorrhage a type of hemorrhagic stroke in which bleeding within the brain caused by a rupture of a blood vessel occurs; often caused by hypertension and is associated with increased intracranial pressure ischemic stroke stroke that results from inadequate blood flow to the brain caused by partial or complete occlusion of an artery lacunar stroke a stroke resulting from occlusion of a small penetrating artery with development of a cavity in the place of the infarcted brain tissue stroke death of brain cells that occurs when there is ischemia (inadequate blood flow) to a part of the brain or hemorrhage into the brain subarachnoid hemorrhage a stroke resulting from intracranial bleeding into the cerebrospinal fluid-filled space between the arachnoid and pia mater membranes on the surface of the brain thrombotic stroke a stroke resulting from thrombosis or narrowing of the blood vessel transient ischemic attack (TIA) a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, but without acute infarction of the brain. Clinical symptoms typically last less than 1 hour 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). ANS: 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. DIF: Cognitive Level: Apply (application) REF: 1391 | 1396 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 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. ANS: 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. DIF: Cognitive Level: Apply (application) REF: TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 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 ANS: 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. DIF: Cognitive Level: Apply (application) REF: 1407 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 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. ANS: 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. DIF: Cognitive Level: Apply (application) REF: 1393 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 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. ANS: 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. DIF: Cognitive Level: Apply (application) REF: 1398 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 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." ANS: 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. DIF: Cognitive Level: Understand (comprehension) REF: 1397 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 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. ANS: 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. DIF: Cognitive Level: Apply (application) REF: 1397 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 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. ANS: 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. DIF: Cognitive Level: Apply (application) REF: 1391 | 1398 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 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. ANS: 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. DIF: Cognitive Level: Apply (application) REF: 1407 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 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. ANS: 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. DIF: Cognitive Level: Apply (application) REF: 1407 TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity 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. ANS: 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. DIF: Cognitive Level: Apply (application) REF: 1407 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 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. ANS: 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. DIF: Cognitive Level: Apply (application) REF: 1407 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 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. ANS: 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. DIF: Cognitive Level: Apply (application) REF: 1405 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 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. ANS: 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. DIF: Cognitive Level: Apply (application) REF: 1406 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 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 ANS: 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. DIF: Cognitive Level: Apply (application) REF: 1409 TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 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. ANS: 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. DIF: Cognitive Level: Apply (application) REF: 1406 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 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. ANS: 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. DIF: Cognitive Level: Apply (application) REF: 1396 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 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). ANS: 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. DIF: Cognitive Level: Apply (application) REF: 1396 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 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. ANS: 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. DIF: Cognitive Level: Apply (application) REF: 1409 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 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. ANS: 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.