NP 2 Chapter 58
Terms in this set (29)
The nurse expects that management of the patient who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects will include
a. prophylactic clipping of cerebral aneurysms.
b. heparin via continuous intravenous infusion.
c. oral administration of low dose aspirin therapy.
d. therapy with tissue plasminogen activator (tPA).
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.
Aspirin is ordered for a patient who is admitted with a possible stroke. Which information obtained during the admission assessment indicates that the nurse should consult with the health care provider before giving the aspirin?
a. The patient has dysphasia.
b. The patient has atrial fibrillation.
c. The patient states, "My symptoms started with a terrible headache."
d. The patient has a history of brief episodes of right-sided hemiplegia.
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.
A patient with a stroke experiences right-sided arm and leg paralysis and facial drooping on the right side. When admitting the patient, which clinical manifestation will the nurse expect to find?
a. Impulsive behavior
b. Right-sided neglect
c. Hyperactive left-sided reflexes
d. Difficulty in understanding commands
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.
The nurse receives a verbal report that a patient has an occlusion of the left posterior cerebral artery. The nurse will anticipate that the patient may have
c. visual deficits.
d. poor judgment.
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.
The health care provider prescribes clopidogrel (Plavix) for a patient with cerebral atherosclerosis. When teaching about the new medication, the nurse will tell the patient
a. to monitor and record the blood pressure daily.
b. to call the health care provider if stools are tarry.
c. that Plavix will dissolve clots in the cerebral arteries.
d. that Plavix will reduce cerebral artery plaque formation.
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.
The health care provider recommends a carotid endarterectomy for a patient with carotid atherosclerosis and a history of transient ischemic attacks (TIAs). The patient asks the nurse to describe the procedure. Which response by the nurse is appropriate?
a. "The carotid endarterectomy involves surgical removal of plaque from an artery in the neck."
b. "The diseased portion of the artery in the brain is removed and 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."
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 removed" 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 MERCI procedure.
When assessing a patient with a possible stroke, the nurse finds that the patient's aphasia started 3.5 hours previously and the blood pressure is 170/92 mm Hg. Which of these orders by the health care provider should the nurse question?
a. Infuse normal saline at 75 mL/hr.
b. Keep head of bed elevated at least 30 degrees.
c. Administer tissue plasminogen activator (tPA) per protocol.
d. Titrate labetalol (Normodyne) drip to keep BP less than 140/90 mm Hg.
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.
A patient with a history of several transient ischemic attacks (TIAs) arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. The nurse anticipates the need to prepare the patient for
a. surgical endarterectomy.
b. transluminal angioplasty.
c. intravenous heparin administration.
d. tissue plasminogen activator (tPA) infusion.
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.
The nurse identifies the nursing diagnosis of impaired verbal communication for a patient with expressive aphasia. An appropriate nursing intervention to help the patient communicate is to
a. have the patient practice facial and tongue exercises.
b. ask simple questions that the patient can answer with "yes" or "no."
c. develop a list of words that the patient can read and practice reciting.
d. prevent embarrassing the patient by changing the subject if the patient does not respond.
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.
A patient has a stroke affecting the right hemisphere of the brain. Based on knowledge of the effects of right brain damage, the nurse establishes a nursing diagnosis of
a. impaired physical mobility related to right hemiplegia.
b. risk for injury related to denial of deficits and impulsiveness.
c. impaired verbal communication related to speech-language deficits.
d. ineffective coping related to depression and distress about disability.
Right-sided brain damage typically causes denial of any deficits and 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.
When caring for a patient with left-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care during the acute period of the stroke?
a. Apply an eye patch to the left eye.
b. Approach the patient from the left side.
c. Place objects needed for activities of daily living on the patient's right side.
d. Reassure the patient that the visual deficit will resolve as the stroke progresses.
During the acute period, the nurse should place objects on the patient's unaffected side. Since there is a visual defect in the left half of each eye, an eye patch is not appropriate. The patient should be approached from the right side. The visual deficit may not resolve, although the patient can learn to compensate for the defect.
The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to impaired self-feeding ability for a patient with right-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 left hand.
d. Teach the patient the "chin-tuck" technique.
Because the nursing diagnosis indicates that the patient's imbalanced nutrition is related to the right-sided hemiplegia, the appropriate interventions will focus on teaching the patient to use the left hand for self-feeding. The other interventions are appropriate for patients with other etiologies for the imbalanced nutrition.
A 32-year-old patient has a stroke resulting from a ruptured aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan?
a. Applying intermittent pneumatic compression stockings
b. Assisting to dangle on edge of bed and assess for dizziness
c. Encouraging patient to cough and deep breathe every 4 hours
d. Inserting an oropharyngeal airway to prevent airway obstruction
The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thromboemboism (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.
A patient who has had a stroke has a new order to attempt oral feedings. 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.
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.
A patient who has right-sided weakness after a stroke is attempting to use the left hand for feeding and other activities. The patient's wife insists on feeding and dressing him, telling the nurse, "I just don't like to see him struggle." Which nursing diagnosis is most appropriate for the patient?
a. Situational low self-esteem related to increasing dependence on others
b. Interrupted family processes related to effects of illness of a family member
c. Disabled family coping related to inadequate understanding by patient's spouse
d. Impaired nutrition: less than body requirements related to hemiplegia and aphasia
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.
Several weeks after a stroke, a patient has urinary incontinence resulting from an impaired awareness of bladder fullness. For an effective bladder training program, which nursing intervention will be best to include in the plan of care?
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.
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.
A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering the medications, the patient says, "I don't need the aspirin today. I don't have any aches or pains." 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 aches.
c. Explain that the aspirin is ordered to decrease stroke risk.
d. Call the health care provider to clarify the medication order.
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.
A patient is admitted to the hospital with dysphasia and right-sided weakness that resolves in a few hours. The nurse will anticipate teaching the patient about
a. alteplase (tPA).
b. aspirin (Ecotrin).
c. warfarin (Coumadin).
d. nimodipine (Nimotop).
Following a 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.
A patient with a left-sided 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.
Patients who have left-sided brain stroke are prone to emotional outbursts, which 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.
The nurse obtains all of the following information about a 65-year-old patient in the clinic. When developing a plan to decrease stroke risk, which risk factor is most important for the nurse to address?
a. The patient has a daily glass of wine to relax.
b. The patient is 25 pounds above the ideal weight.
c. The patient works at a desk and relaxes by watching television.
d. The patient's blood pressure (BP) is usually about 180/90 mm Hg.
Hypertension is the single most important modifiable risk factor and this patient's hypertension is at the stage 2 level. 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 so much as hypertension.
A patient with sudden-onset right-sided weakness has a CT scan and is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider?
a. The patient's speech is difficult to understand.
b. The patient's blood pressure is 144/90 mm Hg.
c. The patient takes a diuretic because of a history of hypertension.
d. The patient has atrial fibrillation and takes warfarin (Coumadin).
The use of warfarin will have contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patient's care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated.
A patient with right-sided weakness that started 90 minutes earlier is admitted to the emergency department and all these diagnostic tests are ordered. Which test should be done first?
a. Electrocardiogram (ECG)
b. Complete blood count (CBC)
c. Chest radiograph (Chest x-ray)
d. Noncontrast computed tomography (CT) scan
Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 4.5 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the smaller the area of brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.
A patient with a stroke has progressive development of neurologic deficits with increasing weakness and decreased level of consciousness (LOC). Which nursing diagnosis has the highest priority for the patient?
a. Impaired physical mobility related to weakness
b. Disturbed sensory perception related to brain injury
c. Risk for impaired skin integrity related to immobility
d. Risk for aspiration related to inability to protect airway
Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other diagnoses also are appropriate, but interventions to prevent aspiration are the priority at this time.
A patient who has had a subarachnoid hemorrhage is being cared for in the intensive care unit. Which information about the patient is most important to communicate to the health care provider?
a. The patient's blood pressure is 90/50 mm Hg.
b. The patient complains about having a stiff neck.
c. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).
d. The patient complains of an ongoing severe headache.
To prevent cerebral vasospasm and maintain cerebral perfusion, blood pressure needs to be maintained at a level higher than 90 mm Hg systolic after a subarachnoid hemorrhage. A low BP or drop in BP indicates a need to administer fluids and/or vasopressors to increase the BP. An ongoing headache, RBCs in the CSF, and a stiff neck are all typical clinical manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the health care provider.
Which of these nursing actions included in the care of a patient who has been experiencing stroke symptoms for 60 minutes can the nurse delegate to an LPN/LVN?
a. Assess the patient's gag and cough reflexes.
b. Determine when the stroke symptoms began.
c. Administer the prescribed clopidogrel (Plavix).
d. Infuse the prescribed IV metoprolol (Lopressor).
Administration of oral medications is included in LPN education and scope of practice. The other actions require more education and scope of practice and should be done by the RN.
After receiving change-of-shift report on the following four patients, which patient should the nurse see first?
a. A patient with right-sided weakness who has an infusion of tPA prescribed
b. A patient who has atrial fibrillation and a new order for warfarin (Coumadin)
c. A patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due
d. A patient with a subarachnoid hemorrhage 2 days ago who has nimodipine (Nimotop) scheduled
tPA needs to be infused within the first few hours after stroke symptoms start in order to be effective in minimizing brain injury. The other medications also should be given as quickly as possible, but timing of the medications is not as critical.
The nurse is caring for a patient with carotid artery narrowing who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse?
a. The pulse rate is 104 beats/min.
b. The patient has difficulty talking.
c. The blood pressure is 142/88 mm Hg.
d. There are fine crackles at the lung bases.
Small emboli can occur during carotid artery angioplasty and stenting, and the aphasia indicates a possible stroke during the procedure. Slightly elevated pulse rate and blood pressure are not unusual because of anxiety associated with the procedure. Fine crackles at the lung bases may indicate atelectasis caused by immobility during the procedure; the nurse should have the patient take some deep breaths.
A patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first?
a. Check the respiratory rate.
b. Monitor the blood pressure.
c. Send the patient for a CT scan.
d. Obtain the Glasgow Coma Scale score.
The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, circulation) are completed.
A 58-year-old patient who began experiencing right-sided arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________
a. Obtain CT scan without contrast.
b. Infuse tissue plasminogen activator (tPA).
c. Administer oxygen to keep O2 saturation >95%.
d. Use National Institute of Health Stroke Scale to assess patient
C, D, A, B
The initial actions should be those that help with airway, breathing, and circulation. Baseline neurologic assessments should be done next. A CT scan will be needed to rule out hemorrhagic stroke before tPA can be administered.