Stroke Nclex Flashcards Quizlet PDF

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30 terms

Stroke NCLEX

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Terms in this set (30) After a patient experienced a

C. The patient's symptoms are consistent with transient ischemic attack (TIA),

brief episode of tinnitus,

and drugs that inhibit platelet aggregation are prescribed after a TIA to

diplopia, and dysarthria with no

prevent stroke. Continuous heparin infusion is not routinely used after TIA or

residual effects, the nurse

with acute ischemic stroke. The patient's symptoms are not consistent with a

anticipates teaching the patient

cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA.

about a. cerebral aneurysm clipping. b. heparin intravenous infusion. c. oral low-dose aspirin therapy. d. tissue plasminogen activator (tPA). A 68-year-old patient is being

C. A sudden onset headache is typical of a subarachnoid hemorrhage, and

admitted with a possible stroke.

aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic

Which information from the

attack (TIA) are not contraindications to aspirin use, so the nurse can

assessment indicates that the

administer the aspirin.

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. A 73-year-old patient with a

D. Right-sided paralysis indicates a left-brain stroke, which will lead to

stroke experiences facial

difficulty with comprehension and use of language. The left-side reflexes are

drooping on the right side and

likely to be intact. Impulsive behavior and neglect are more likely with a

right-sided arm and leg

right-side stroke.

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 During the change of shift report

C. Visual disturbances are expected with posterior cerebral artery occlusion.

a nurse is told that a patient has

Aphasia occurs with middle cerebral artery involvement. Cognitive deficits

an occluded left posterior

and changes in judgment are more typical of anterior cerebral artery

cerebral artery. The nurse will

occlusion.

anticipate that the patient may have a. dysphasia. b. confusion. c. visual deficits. d. poor judgment. When teaching about

D. Clopidogrel (Plavix) inhibits platelet function and increases the risk for

clopidogrel (Plavix), the nurse

gastrointestinal bleeding, so patients should be advised to notify the health

will tell the patient with cerebral

care provider about any signs of bleeding. The medication does not lower

atherosclerosis

blood pressure, decrease plaque formation, or dissolve clots.

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. A patient with carotid

A. In a carotid endarterectomy, the carotid artery is incised and the plaque is

atherosclerosis asks the nurse to

removed. The response beginning, "The diseased portion of the artery in the

describe a carotid

brain is replaced" describes an arterial graft procedure. The answer

endarterectomy. Which response

beginning, "A catheter with a deflated balloon is positioned at the narrow

by the nurse is accurate?

area" describes an angioplasty. The final response beginning, "A wire is

a. "The obstructing plaque is

threaded through the artery" describes the mechanical embolus removal in

surgically removed from an

cerebral ischemia (MERCI) procedure.

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." A patient admitted with possible

D. Because elevated BP may be a protective response to maintain cerebral

stroke has been aphasic for 3

perfusion, antihypertensive therapy is recommended only if mean arterial

hours and his current blood

pressure (MAP) is >130 mm Hg or systolic pressure is >220 mm Hg. Fluid

pressure (BP) is 174/94 mm Hg.

intake should be 1500 to 2000 mL daily to maintain cerebral blood flow. The

Which order by the health care

head of the bed should be elevated to at least 30 degrees, unless the patient

provider should the nurse

has symptoms of poor tissue perfusion. tPA may be administered if the

question?

patient meets the other criteria for tPA use.

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. A 56-year-old patient arrives in

D. The patient's history and clinical manifestations suggest an acute ischemic

the emergency department with

stroke and a patient who is seen within 4.5 hours of stroke onset is likely to

hemiparesis and dysarthria that

receive tPA (after screening with a CT scan). Heparin administration in the

started 2 hours previously, and

emergency phase is not indicated. Emergent carotid transluminal angioplasty

health records show a history of

or endarterectomy is not indicated for the patient who is having an acute

several transient ischemic attacks

ischemic stroke.

(TIAs). The nurse anticipates preparing the patient for a. surgical endarterectomy. b. transluminal angioplasty. c. intravenous heparin administration. d. tissue plasminogen activator (tPA) infusion. A female patient who had a

A. Communication will be facilitated and less frustrating to the patient when

stroke 24 hours ago has

questions that require a "yes" or "no" response are used. When the language

expressive aphasia. The nurse

areas of the brain are injured, the patient might not be able to read or recite

identifies the nursing diagnosis

words, which will frustrate the patient without improving communication.

of impaired verbal

Expressive aphasia is caused by damage to the language areas of the brain,

communication. An appropriate

not by the areas that control the motor aspects of speech. The nurse should

nursing intervention to help the

allow time for the patient to respond.

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. A 72-year-old patient who has a

C. Aspirin is ordered to prevent stroke in patients who have experienced

history of a transient ischemic

TIAs. Documentation of the patient's refusal to take the medication is an

attack (TIA) has an order for

inadequate response by the nurse. There is no need to clarify the order with

aspirin 160 mg daily. When the

the health care provider. The aspirin is not ordered to prevent aches and

nurse is administering

pains.

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. For a patient who had a right

A. The patient with right-sided brain damage typically denies any deficits and

hemisphere stroke the nurse

has poor impulse control, leading to risk for injury when the patient attempts

establishes a nursing diagnosis

activities such as transferring from a bed to a chair. Right-sided brain damage

of

causes left hemiplegia. Left-sided brain damage typically causes language

a. risk for injury related to denial

deficits. Left-sided brain damage is associated with depression and distress

of deficits and impulsiveness.

about the disability.

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. A patient in the clinic reports a

B. Following a transient ischemic attack (TIA), patients typically are started on

recent episode of dysphasia and

medications such as aspirin to inhibit platelet function and decrease stroke

left-sided weakness at home that

risk. tPA is used for acute ischemic stroke. Coumadin is usually used for

resolved after 2 hours. The nurse

patients with atrial fibrillation. Nimodipine is used to prevent cerebral

will anticipate teaching the

vasospasm after a subarachnoid hemorrhage.

patient about

a. alteplase (tPA). b. aspirin (Ecotrin). c. warfarin (Coumadin). d. nimodipine (Nimotop). When caring for a patient with a

C. During the acute period, the nurse should place objects on the patient's

new right-sided homonymous

unaffected side. Because there is a visual defect in the right half of each eye,

hemianopsia resulting from a

an eye patch is not appropriate. The patient should be approached from the

stroke, which intervention should

left side. The visual deficit may not resolve, although the patient can learn to

the nurse include in the plan of

compensate for the defect.

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. A 58-year-old patient with a left-

D. Patients who have left-sided brain stroke are prone to emotional outbursts

brain stroke suddenly bursts into

that are not necessarily related to the emotional state of the patient.

tears when family members visit.

Depression after a stroke is common, but the suddenness of the patient's

The nurse should

outburst suggests that depression is not the major cause of the behavior. The

a. use a calm voice to ask the

family should stay with the patient. The crying is not within the patient's

patient to stop the crying

control and asking the patient to stop will lead to embarrassment.

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. The nurse identifies the nursing

C. Because the nursing diagnosis indicates that the patient's imbalanced

diagnosis of imbalanced

nutrition is related to the left-sided hemiplegia, the appropriate interventions

nutrition: less than body

will focus on teaching the patient to use the right hand for self-feeding. The

requirements related to impaired

other interventions are appropriate for patients with other etiologies for the

self-feeding ability for a left-

imbalanced nutrition.

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 "chintuck" technique. Which stroke risk factor for a 48-

C. Hypertension is the single most important modifiable risk factor. People

year-old male patient in the

who drink more than 1 (for women) or 2 (for men) alcoholic beverages a day

clinic is most important for the

may increase risk for hypertension. Physical inactivity and obesity contribute

nurse to address?

to stroke risk but not as much as hypertension.

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. A 40-year-old patient has a

A. The patient with a subarachnoid hemorrhage usually has minimal activity to

ruptured cerebral aneurysm and

prevent cerebral vasospasm or further bleeding and is at risk for venous

subarachnoid hemorrhage.

thromboembolism (VTE). Activities such as coughing and sitting up that might

Which intervention will be

increase intracranial pressure (ICP) or decrease cerebral blood flow are

included in the care plan?

avoided. Because there is no indication that the patient is unconscious, an

a. Apply intermittent pneumatic

oropharyngeal airway is inappropriate.

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. A patient in the emergency

D. The use of warfarin probably contributed to the intracerebral bleeding

department with sudden-onset

and remains a risk factor for further bleeding. Administration of vitamin K is

right-sided weakness is

needed to reverse the effects of the warfarin, especially if the patient is to

diagnosed with an intracerebral

have surgery to correct the bleeding. The history of hypertension is a risk

hemorrhage. Which information

factor for the patient but has no immediate effect on the patient's care. The

about the patient is most

BP of 144/90 indicates the need for ongoing monitoring but not for any

important to communicate to the

immediate change in therapy. Slurred speech is consistent with a left-sided

health care provider?

stroke, and no change in therapy is indicated.

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). A 47-year-old patient will

C. The patient should be as upright as possible before attempting feeding to

attempt oral feedings for the first

make swallowing easier and decrease aspiration risk. To assess swallowing

time since having a stroke. The

ability, the nurse should initially offer water or ice to the patient. Pureed diets

nurse should assess the gag

are not recommended because the texture is too smooth. The patient may

reflex and then

have a poor appetite, but the oral feeding should be attempted regardless.

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. A patient with left-sided

D. Rapid screening with a noncontrast CT scan is needed before

weakness that started 60 minutes

administration of tissue plasminogen activator (tPA), which must be given

earlier is admitted to the

within 4.5 hours of the onset of clinical manifestations of the stroke. The

emergency department and

sooner the tPA is given, the less brain injury. The other diagnostic tests give

diagnostic tests are ordered.

information about possible causes of the stroke and do not need to be

Which test should be done first?

completed as urgently as the CT scan.

a. Complete blood count (CBC) b. Chest radiograph (Chest x-ray) c. 12-Lead electrocardiogram (ECG) d. Noncontrast computed tomography (CT) scan A male patient who has right-

C. The information supports the diagnosis of disabled family coping because

sided weakness after a stroke is

the wife does not understand the rehabilitation program. There are no data

making progress in learning to

supporting low self-esteem, and the patient is attempting independence. The

use the left hand for feeding and

data do not support an interruption in family processes because this may be

other activities. The nurse

a typical pattern for the couple. There is no indication that the patient has

observes that when the patient's

impaired nutrition.

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 Nurses in change-of-shift report

D. Protection of the airway is the priority of nursing care for a patient having

are discussing the care of a

an acute stroke. The other diagnoses are also appropriate, but interventions

patient with a stroke who has

to prevent aspiration are the priority at this time.

progressively increasing weakness and decreasing level of consciousness (LOC). Which nursing diagnosis do they determine 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 Several weeks after a stroke, a

B. Developing a regular voiding schedule will prevent incontinence and may

50-year-old male patient has

increase patient awareness of a full bladder. A 1200 mL fluid restriction may

i...