NCLEX Neuro assess, TIA, stroke, ICP
Terms in this set (52)
Which statement is true for a patient who has pathology in Wernicke's area of the cerebrum?
A. Receptive speech is affected.
B. The parietal lobe is involved.
C. Sight processing is abnormal.
D. An abnormal Romberg test is present.
The temporal, not parietal, lobe contains the Wernicke area, which is responsible for receptive speech and integration of somatic, visual, and auditory data. Sight processing occurs in the occipital lobe. The Romberg test is used to assess the position sense of the lower extremities.
After a major head trauma, the patient's respiratory and cardiac functions are affected. Which area of the brain is damaged?
A. Temporal lobe of the cerebrum
D. Spinal nerves
The brainstem includes the midbrain, pons, and medulla. The vital centers concerned with respiratory, vasomotor, and cardiac function are located in the medulla. Integration of somatic, visual, and auditory data occurs in the temporal lobe. The cerebellum coordinates voluntary movement, trunk stability, and equilibrium. Motor and spinal nerves serve particular areas of the body.
What is the purpose of the blood-brain barrier?
A. To protect the brain by cushioning
B. To inhibit damage from external trauma
C. To keep harmful agents away from brain tissue
D. To provide the blood supply to brain tissue
The blood-brain barrier is a physiologic barrier between capillaries and brain tissue. The structure of the brain's capillaries is different from others, and substances that are harmful are not allowed to enter brain tissue. Lipid-soluble compounds enter the brain easily, but water-soluble and ionized drugs enter slowly. The spinal fluid and meninges help cushion the brain. The skull protects from external trauma. Blood is supplied to the brain from the internal carotid arteries and the vertebral arteries.
An obstruction of the anterior cerebral arteries affects
A. visual imaging.
B. balance and coordination.
C. judgment, insight, and reasoning.
D. visual and auditory integration for language comprehension.
The anterior cerebral artery feeds the medial and anterior portions of the frontal lobes. The anterior portion of the frontal lobe controls higher-order processes such as judgment and reasoning.
Paralysis of lateral gaze indicates a lesion of cranial nerve
Cranial nerves III (oculomotor), IV (trochlear), and VI (abducens) are responsible for eye movement. The lateral rectus eye muscle is innervated by cranial nerve VI and is the primary muscle that is responsible for lateral eye movement
What is important when obtaining a history of a patient with a neurologic problem?
A. Have patient agree or disagree with suggested symptoms to obtain a thorough history.
B. Mode of onset and course of illness are essential aspects.
C. Check out neurologic problems caused by nutrition by asking about sodium.
D. Assess for dementia using the Confusion Assessment Method (CAM).
The mode of onset and the course of the illness are especially important aspects of the history. The nature of a neurologic disease process often can be described by these facts alone. Avoid suggesting certain symptoms or using leading questions. Nutritional deficits of B vitamins are most likely to cause neurologic problems. CAM is used to assess for delirium.
What is the most common visual field change resulting from a brain lesion?
B. Blurred vision
Visual field changes resulting from brain lesions are usually diagnosed as hemianopsia (one half of the visual field) or quadrantanopsia (one fourth of the visual field) or monocular vision.
When assessing a patient with a traumatic brain injury, you notice uncoordinated movement of the extremities. How would you document this?
Ataxia is a lack of coordination of movement, possibly caused by lesions of sensory or motor pathways, cerebellar disorders, or certain medications.
How do you assess the accessory nerve?
A. Assess the gag reflex by stroking the posterior pharynx.
B. Ask the patient to shrug the shoulders against resistance.
C. Ask the patient to push the tongue to either side against resistance.
D. Have the patient say "ah" while visualizing elevation of the soft palate
The spinal accessory nerve is tested by asking the patient to shrug the shoulders against resistance and to turn the head to either side against resistance. The other options are used to test the glossopharyngeal and vagus nerves.
When assessing motor function of a patient admitted with a stroke, you notice mild weakness of the arm demonstrated by downward drifting of the extremity. How would you accurately document this finding?
D. Pronator drift
Downward drifting of the arm or pronation of the palm is identified as pronator drift. Hemiparesis is weakness of one side of the body, hypotonia describes flaccid muscle tone, and athetosis is a slow, writhing, involuntary movement of the extremities
A patient's sudden onset of hemiplegia has necessitated a computed tomography (CT) of her head. Which assessment should you complete before this diagnostic study?
A. Assess the patient's immunization history.
B. Screen the patient for any metal parts or a pacemaker.
C. Assess the patient for allergies to shellfish, iodine, or dyes.
D. Assess the patient's need for tranquilizers or antiseizure medications.
Allergies to shellfish, iodine, or dyes contraindicate the use of contrast media for CT. The patient's immunization history is not a central consideration, and the presence of metal in the body does not preclude the use of CT as a diagnostic tool. The need to assess for allergies supersedes the need for tranquilizers or antiseizure medications in most patients.
How should you most accurately assess the position sense of a patient with a recent traumatic brain injury?
A. Ask the patient to close his or her eyes and slowly bring the tips of the index fingers together.
B. Ask the patient to maintain balance while standing with his or her feet together and eyes closed.
C. Ask the patient to close his or her eyes and identify the presence of a common object on the forearm.
D. Place the two points of a calibrated compass on the tips of the fingers and toes, and ask the patient to discriminate the points.
The Romberg test is an assessment of position sense in which the patient stands with the feet together and then closes his or her eyes while attempting to maintain balance. The other tests of neurologic function do not directly assess position sense.
Why are the data regarding mobility, strength, coordination, and activity tolerance important for you to obtain?
A. Many neurologic diseases affect one or more of these areas.
B. Patients are less able to identify other neurologic impairments.
C. These are the first functions to be affected by neurologic disease.
D. Aspects of movement are the most important function of the nervous system.
Many neurologic disorders can cause problems in the patient's mobility, strength, and coordination. These problems can result in changes in the patient's usual activity and exercise patterns.
Which option indicates a sign of Cushing's triad, an indication of increased intracranial pressure (ICP)?
A. Heart rate increases from 90 to 110 beats/minute
B. Kussmaul respirations
C. Temperature over 100.4° F (38° C)
D. Heart rate decreases from 75 to 55 beats/minute
Cushing's triad is systolic hypertension with a widening pulse pressure, bradycardia with a full and bounding pulse, and slowed respirations. The rise in blood pressure is an attempt to maintain cerebral perfusion, and it is a neurologic emergency because decompensation is imminent. The other options are not part of Cushing's triad.
The patient had an acute ischemic stroke 4 hours ago and has an elevated blood pressure. What action should you take?
A. Document the findings because the increased pressure is needed to perfuse the brain.
B. Administer an antihypertensive medication to prevent additional damage.
C. Hyperventilate the patient to cause vasodilatation.
D. Teach patient about a low sodium diet.
After a stroke, temporary hypertension is needed to perfuse the area of swelling. No treatment is done unless the pressure is above 220/110 mm Hg in the first few hours. Aggressive lowering of blood pressure is not done, because if the pressure drops, it can prevent regional perfusion and lead to local tissue damage. Hyperventilation is done if hypercapnia is identified, but it is not prophylactic.
Which response can be expected in a patient with low oxygen concentration and acidosis?
A. Decreased cerebral fluid flow with decreased cerebral pressure
B. Vasodilation with increased cerebral pressure
C. Systemic hypotension with decreased cerebral pressure
D. Cerebral tissue hypertrophy with increased cerebral pressure
Low concentration of oxygen ions and high concentration of hydrogen ions cause vasodilation, which can result in increased ICP if autoregulation has failed. The other options are not possible
A patient being monitored has an ICP pressure of 12 mm Hg. You understand that this pressure reflects
A. a severe decrease in cerebral perfusion pressure.
B. an alteration in the production of cerebrospinal fluid.
C. the loss of autoregulatory control of intracranial pressure.
D. a normal balance between brain tissue, blood, and cerebrospinal fluid.
Normal ICP ranges from 10 to 15 mm Hg. A sustained pressure above the upper limit is considered abnormal.
Which option is the most sensitive indication of increased ICP?
B. Cushing's triad
C. Projectile vomiting
D. Change in the level of consciousness (LOC)
The LOC is the most sensitive and reliable indicator of the patient's neurologic status. Changes in LOC are a result of impaired cerebral brain flow. Papilledema and Cushing's triad are late signs. Projectile vomiting is not a sensitive indicator.
What sign would make you suspect the cause of increased ICP involves the hypothalamus?
A. Contralateral hemiparesis
B. Ipsilateral pupil dilation
C. Rise in temperature
D. Decreased urine output
If the ICP affects the hypothalamus, there can be a change in the body temperature. Increasing ICP can cause changes in motor ability, with contralateral hemiparesis. Compression of the cranial nerve III causes dilation of the pupil on the side of the mass (ipsilateral). Decreased urine output is not specific for hypothalamic function.
A patient with increased ICP has mannitol (Osmitrol) prescribed. Which option is the best indication that the drug is achieving the desired therapeutic effects?
A. Urine output increases from 30 mL to 50 mL/hour.
B. Blood pressure remains less than 150/90 mm Hg.
C. The LOC improves.
D. No crackles are auscultated in the lung fields.
LOC is the most sensitive indicator of ICP. Mannitol is an osmotic diuretic that works to decrease the ICP by plasma expansion and an osmotic effect. Although the other options may indicate a therapeutic effect of a diuretic, they are not the main reason this drug is given.
A patient with increased ICP is being monitored in the intensive care unit (ICU) with a fiberoptic catheter. Which order is a priority for you?
A. Perform hourly neurologic checks.
B. Take a complete set of vital signs.
C. Administer the prescribed mannitol (Osmitrol).
D. Give an H2-receptor blocker.
he priority is to treat the known existing problem, and mannitol is the only thing that can do that. Because the patient is having the current pressure measured with objective numbers, treating the known problem is a priority over additional assessments. H2-blockers are given when corticosteroids are administered to help prevent gastrointestinal bleeding, but they are not a priority compared with the treatment of ICP.
What is the standard to evaluate the degree of impaired consciousness for a patient with an acute head trauma?
A. Best eye opening, verbal response, and motor response
B. National Institutes of Health (NIH) Stroke Scale
C. Romberg test
D. Widening pulse pressure, bradycardia, and respirations
The Glasgow Coma Scale (GCS) is a standardized tool used to assess the degree of impaired consciousness, and it consists of three components. The NIH stroke scale is used for a suspected stroke and includes other components of cranial nerve assessment, motor testing, and sensory testing. The Romberg test measures balance and is used for suspected cerebellar dysfunction. The components in the last option are Cushing's triad and an indication of increased ICP, not LOC.
Vasogenic cerebral edema increases ICP by
A. shifting fluid in the gray matter.
B. altering the endothelial lining of cerebral capillaries.
C. leaking molecules from the intracellular fluid to the capillaries.
D. altering the osmotic gradient flow into the intravascular component.
Vasogenic cerebral edema occurs mainly in the white matter and is caused by changes in the endothelial lining of cerebral capillaries.
You plan care for the patient with increased ICP with the knowledge that the best way to position the patient is to
A. keep the head of the bed flat.
B. elevate the head of the bed to 30 degrees.
C. maintain patient on the left side with the head supported on a pillow.
D. use a continuous-rotation bed to continuously change patient position.
You should maintain the patient with increased ICP in the head-up position. Elevation of the head of the bed to 30 degrees enhances respiratory exchange and aids in decreasing cerebral edema. You should position the patient to prevent extreme neck flexion, which can cause venous obstruction and contribute to elevated ICP. Elevation of the head of the bed reduces sagittal sinus pressure, promotes drainage from the head through the valveless venous system in the jugular veins, and decreases the vascular congestion that can produce cerebral edema. However, raising the head of the bed above 30 degrees may decrease the cerebral perfusion pressure (CPP) by lowering systemic blood pressure. Careful evaluation of the effects of elevation of the head of the bed on the ICP and the CPP is required.
Which nursing action should be implemented in the care of a patient who is experiencing increased ICP?
A. Monitor fluid and electrolyte status astutely.
B. Position the patient in a high-Fowler's position.
C. Administer vasoconstrictors to maintain cerebral perfusion.
D. Maintain physical restraints to prevent episodes of agitation.
Fluid and electrolyte disturbances can have an adverse effect on ICP and must be vigilantly monitored. The head of the patient's bed should be kept at 30 degrees in most circumstances, and physical restraints are not applied unless absolutely necessary. Vasoconstrictors are not typically administered in the treatment of ICP.
Which option is most indicative of a skull fracture after blunt head trauma?
A. Facial edema
C. Otorrhea positive for glucose
D. Laceration oozing blood
An indication of a basal fracture is cerebrospinal fluid (CSF) leakage from the ear, which confirms that the fracture has traversed the dura. Periorbital ecchymosis can indicate a skull fracture, but generalized facial edema does not. The head is vascular, and it is not unusual to have a nosebleed; a positive ring sign (halo sign) indicates a skull fracture. A superficial laceration does not indicate a skull fracture.
An elderly patient fell at home. Which information from the patient's history makes this patient at high risk for an intracerebral bleed?
A. History of a heart condition
B. Taking warfarin (Coumadin)
C. Has lost consciousness for 5 seconds
D. History of migraine headaches
Anticoagulant use is associated with increased hemorrhage and more severe head injury. A heart condition may have caused the syncope that caused the fall, but it was not solely responsible for increased bleeding. Concussions are usually minor injuries that resolve, and the typical signs include a brief disruption in level of consciousness (LOC). If the loss of consciousness is less than 5 minutes, patients are usually discharged. Headache by itself does not indicate a risk for intracerebral bleeding.
The patient reports falling when he his foot got "stuck" on a crack in the sidewalk, hitting his head when he fell, and "passing out". The paramedics found the patient walking at the scene and talking before transporting the patient to the hospital. In the emergency department, the patient starts to lose consciousness. This is a classic scenario for which complication?
A. Epidural hematoma
B. Subdural hematoma
C. Subarachnoid bleed
D. Diffuse axial inju
Epidural hematoma often results from a linear fracture crossing a major artery in the dura. The classic sign is an initial period of unconsciousness at the scene and a brief lucid interval followed by a decrease in LOC. A subdural hematoma often results from injury to the brain and veins and develops more slowly. The classic sign or symptom of subarachnoid hemorrhage is a patient describing "the worst headache of my life." Diffuse axonal injury is widespread axonal damage occurring after a traumatic brain injury.
The patient has rhinorrhea after a head injury. What action should you take?
A. Pack the nares with sterile gauze.
B. A loose collection pad may be placed under the nose.
C. Suction the drainage with an inline suction catheter.
D. Obtain a sample for culture.
A loose collection pad may be placed under the nose. Do not place a dressing in the nasal cavity, and nothing should be placed inside the nostril. There is no need to culture the drainage. The concern is whether it is spinal fluid, which is determined by a test for glucose or the halo or ring sign.
The patient had a blunt head injury. What is most important for you to do before the patient's discharge?
A. Have the patient sign the discharge papers.
B. Teach the patient how to perform the Glasgow Coma Scale (GCS).
C. Tell the patient to return if he has a headache.
D. Ensure there is a responsible adult to check on the patient
Complications from a head injury can arise 2 to 3 days later, and the discharged patient must have a responsible adult who can stay with or check on the patient. The patient may understand the instructions but without an objective observer, he or she would not be aware whether some of the key symptoms were occurring. A patient would not know how to do the GCS if impaired or confused. A headache is not a concern, but a worsening headache unrelieved by over-the-counter medications needs to be checked.
You are alerted to a possible acute subdural hematoma in the patient who
A. has a linear skull fracture crossing a major artery.
B. has focal symptoms of brain damage with no recollection of a head injury.
C. develops decreasing LOC and a headache within 48 hours of a head injury.
D. has an immediate loss of consciousness with a brief lucid interval followed by decreasing LOC.
An acute subdural hematoma manifests within 24 to 48 hours of the injury. The signs and symptoms are similar to those associated with brain tissue compression by increased intracranial pressure (ICP) and include decreasing LOC and headache.
During admission of a patient with a severe head injury to the emergency department, you place the highest priority on assessment of
A. patency of airway.
B. presence of a neck injury.
C. neurologic status with the Glasgow Coma Scale.
D. cerebrospinal fluid leakage from the ears or nose.
An initial priority in the emergency management of a patient with a severe head injury is for you to ensure that the patient has a patent airway.
A patient with a suspected closed head injury has bloody nasal drainage. You suspect that this patient has a cerebrospinal fluid (CSF) leak when observing which of the following?
A. A halo sign on the nasal drip pad
B. Decreased blood pressure and urinary output
C. A positive reading for glucose on a Test-tape strip
D. Clear nasal drainage along with the bloody discharge
When drainage containing CSF and blood is allowed to drip onto a white pad, the blood coalesces into the center within a few minutes, and a yellowish ring of CSF encircles the blood, giving a halo effect. The presence of glucose is unreliable for determining the presence of CSF because blood also contains glucose.
You are caring for a patient admitted with a subdural hematoma after a motor vehicle accident. Which change in vital signs would you interpret as a manifestation of increased intracranial pressure?
D. Narrowing pulse pressure
Changes in vital signs indicative of increased ICP are known as Cushing's triad, which consists of increasing systolic pressure with a widening pulse pressure, bradycardia with a full and bounding pulse, and irregular respirations.
You are providing care for a patient who has been admitted to the hospital with a head injury who requires regular neurologic vital signs. Which assessments are components of the patient's score on the Glasgow Coma Scale (select all that apply)?
A. Eye opening
B. Abstract reasoning
C. Best verbal response
D. Best motor response
E. Cranial nerve function
The three dimensions of the Glasgow Coma Scale are eye opening, best verbal response, and best motor response.
The patient is diagnosed with a brain tumor. Which option is the correct understanding of the preferred treatment?
A. Surgical removal is preferred, even if the tumor is not malignant.
B. Chemotherapy is a common and effective treatment.
C. Stereotactic radiosurgery is the preferred treatment.
D. A large dose of intravenous steroid therapy is preferred.
Surgical removal is the preferred treatment. It can reduce tumor mass (decreasing intracranial pressure [ICP]), provides relief of symptoms, and extend survival time. Even a benign mass has a malignant effect by taking up space. Traditional chemotherapy effectiveness is limited because of the blood-brain barrier, tumor cell heterogeneity, and tumor cell drug resistance. Stereotactic radiosurgery delivers a high, concentrated dose of radiation precisely directed and is used when conventional surgery has failed or is not an option. Corticosteroids are not an integral part of therapy, but are used to control complications of radiation therapy.
What is most important finding for you to act on for a patient who had a craniotomy?
A. Sodium: 134 mEq/L
B. While blood cell (WBC) count: 11,000/μL
C. Urine specific gravity: 1.001
D. Blood urea nitrogen (BUN): 25 mg/dL
Patients need frequent monitoring for sodium regulation, onset of diabetes insipidus, and severe hypovolemia. Normal specific gravity for urine should not be below 1.003 and this low value is a priority.
What action should you take as part of care for a patient who had a craniotomy?
A. Use promethazine (Phenergan) for nausea.
B. Position the patient on the operative side if a bone flap was removed.
C. Administer phenytoin (Dilantin) by rapid intravenous push (IVP) every 6 hours.
D. Keep the head in alignment with the trunk.
The primary goal of care after cranial surgery is prevention of increased intracranial pressure (ICP), which includes keeping the body in alignment. Use of promethazine is discouraged because it can increase somnolence and alter the accuracy of a neurologic assessment. The patient is not positioned on the operative side if a bone flap was removed (craniectomy). Dilantin is administered slowly, no faster than 25 to 50 mg/min.
Preventing which problem is a priority nursing goal for a patient who had cranial surgery today?
B. Increased ICP
The primary goal of care after cranial surgery is prevention of increased ICP. Other priorities are monitoring neurologic function, fluid and electrolyte levels, and serum osmolality. The brain does not have pain receptors, although the patient can have a headache. However, increased ICP remains a priority. Infection is not a priority the day of surgery, and nutrition is important, but increased ICP is the priority.
Computed tomography of a 68-year-old patient's head reveals that he has experienced a hemorrhagic stroke. Which option is a nursing priority intervention in the emergency department?
A. Maintenance of the patient's airway
B. Positioning to promote cerebral perfusion
C. Control of fluid and electrolyte imbalances
D. Administration of tissue plasminogen activator (tPA)
Maintenance of a patent airway is the priority in the acute care of a patient with a hemorrhagic stroke, and it supersedes the importance of fluid and electrolyte imbalance and positioning. Use of tPA is contraindicated in hemorrhagic stroke.
A female patient has left-sided hemiplegia after an ischemic stroke that occurred 2 weeks earlier. How should you best promote the integrity of the patient's skin?
A. Position the patient on her weak side most of the time.
B. Alternate the patient between supine and side-lying positions.
C. Avoid the use of pillows to promote independence in positioning.
D. Establish a schedule for the massage of areas where skin breakdown emerges.
A position change schedule should be established for stroke patients. An example is side-backside positioning, 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 a left-brain stroke?
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
Patients with a left-brain 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-brain stroke.
Which of the following patients is at highest risk for a stroke?
A. An obese, 45-year-old Native American
B. A 35-year-old Asian American woman who smokes
C. A 32-year-old, white woman taking oral contraceptives
D. A 65-year-old African American man with hypertension
Nonmodifiable risk factors for stroke include age (>65 years), male gender, ethnicity or race (African Americans > Hispanics, Native Americans/Alaska Natives, and Asian Americans > whites), 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 cholesterol, birth control pills (high levels of progestin and estrogen), history of migraine headaches, inflammatory conditions, hyperhomocysteinemia, and sickle cell disease.
Which factor related to cerebral blood flow most often determines the extent of cerebral damage from a stroke?
A. Amount of cardiac output
B. Oxygen content of the blood
C. Degree of collateral circulation
D. Level of carbon dioxide in the blood
The extent of the stroke depends on rapidity of onset, the size of the lesion, and the presence of collateral circulation.
What information provided by the patient can help differentiate a hemorrhagic stroke from a thrombotic stroke?
A. Sensory disturbance
B. A history of hypertension
C. Presence of motor weakness
D. Sudden onset of severe headache
A hemorrhagic stroke usually causes sudden onset of symptoms, including 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
B. vertebral artery.
C. left middle cerebral artery.
D. right middle cerebral artery.
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.
You explain to the patient with a stroke who is scheduled for angiography that the test is used to determine the
A. presence of increased intracranial pressure (ICP).
B. site and size of the infarction.
C. patency of the cerebral blood vessels.
D. presence of blood in the cerebrospinal fluid.
Angiography provides visualization of cerebral blood vessels, can provide an estimate of perfusion, and can detect filling defects in the cerebral arteries.
A patient experiencing TIAs is scheduled for a carotid endarterectomy. You explain 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.
In carotid endarterectomy, the atheromatous lesions are removed from the carotid artery to improve blood flow.
For a patient with a suspected stroke, which important piece of information should you obtain?
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
During initial evaluation, the single most important point in the patient's history is the time of 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; tPA reestablishes blood flow through a blocked artery and prevents brain cell death in patients with an acute onset of symptoms.
Bladder training for 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.
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 given between 8:00 AM and 7:00 PM; (2) scheduled toileting every 2 hours using a bedpan, commode, or bathroom; and (3) observing 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) focusing the patient on the need to urinate with a direct command; (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 (standing for men and sitting for women).
What are the common psychosocial reactions of the patient to the stroke (select all that apply)?
D. Sleep disturbances
E. Denial of the severity of the stroke
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 and 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 well as changing roles and responsibilities. Reactions vary considerably but may involve fear, apprehension, denial of the severity of the stroke, depression, anger, and sorrow.
What is the treatment of choice for normal pressure hydrocephalus?
A. Donepezil (Aricept)
C. Furosemide (Lasix)
Normal pressure hydrocephalus results from an obstruction in the flow of cerebrospinal fluid (CSF), which causes a buildup of CSF fluid in the brain. Manifestations of the condition include dementia, urinary incontinence, and difficulty walking. Meningitis, encephalitis, or head injury may cause the condition. If diagnosed early, it is treated by surgically inserting a shunt to divert the fluid.
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