Question 1

A patient is recovering from a stroke. The family reports to the nurse that the patient alternates between periods of crying for no given reason to periods of laughing inappropriately. Which condition does the nurse suspect the patient is exhibiting?

Accepted Answer

Pseudobulbar effect is a condition often seen in patients recovering from a stroke or other neurological conditions, characterized by involuntary and uncontrollable episodes of crying and/or laughing that are disproportionate or inappropriate to the situation. This condition is distinct from psychotic events, bipolar disorder, and mood swings, which have different underlying causes and manifestations.

Question 2

The nurse is aware that children can be at risk for an embolic stroke. Which condition is least likely to cause a child to have a stroke?

Accepted Answer

Contact sport trauma is less likely to directly cause an embolic stroke compared to the other options. Sickle cell disease, hyperlipidemia, and congenital heart defects are conditions that can lead to blood flow issues or clot formation, directly increasing the risk of an embolic stroke.

Question 3

A patient arrives in the emergency department at 0200 exhibiting the manifestations of a stroke. The patient reports going to bed at 2100 and being negative for symptoms. If the CT reveals an ischemic stroke related to a blood clot, for which reason is tPA therapy withheld?

Accepted Answer

tPA therapy is time-sensitive and must be administered within a specific window from the onset of symptoms. Since the exact time of stroke onset is unknown (the patient was symptom-free at 2100 and symptomatic at 0200), it is assumed to be at the time they were last known to be well, making them ineligible for tPA.

Question 4

A patient began experiencing manifestations of a stroke at 0800 hours. By which time should thrombolytic medications be provided to reverse stroke symptoms? 1.0900 hours

Accepted Answer

Thrombolytic medications should be administered within 4.5 hours of stroke symptom onset, which would be by 1250 hours in this case.

Question 5

The nurse is involved in a blood pressure clinic in the community, and an individual with possible stroke symptoms is brought for evaluation. Which findings in the FAST (Face, Arms, Speech, and Time) assessment indicate the need to call emergency personnel? (Select all that apply.)

Accepted Answer

The answer of The nurse is involved in a blood...

Question 6

The nurse is reviewing the medical records of patients in an HCP's practice. Which patient does the nurse recognize as the greatest risk for a stroke?

Accepted Answer

The answer of The nurse is reviewing the medical records...

Question 7

The nurse is providing care for a patient diagnosed with a stroke resulting in language disorder. Which type of disorder does the nurse recognize if the patient raises an arm in response to the nurse's direction to stick out his tongue?

Accepted Answer

The patient's inability to understand the nurse's verbal instruction, but still attempting a physical response, indicates a problem with language comprehension, which is characteristic of receptive aphasia.

Question 8

The nurse is providing care for a patient diagnosed with a cerebral aneurysm and subarachnoid hemorrhage. Which statement by the patient indicates a need for additional information?

Accepted Answer

Surgery may not cure a cerebral aneurysm and subarachnoid hemorrhage; it aims to prevent further bleeding or rebleeding. The statement suggests a misunderstanding of the treatment's goal.

Question 9

The HCP is preparing to discharge a patient from the hospital after a stroke. The patient is insistent on being sent to a rehabilitation center. The nurse is aware that the patient must meet which qualification to go to rehabilitation?

Accepted Answer

The ability to participate in intensive therapy is a crucial qualification for a patient to be admitted to a rehabilitation center after a stroke. This ensures that the patient can engage actively in the rehabilitation process to maximize recovery.

Question 10

The nurse is providing care for a patient with expressive aphasia. Which intervention does the nurse expect to find in the patient's plan of care? (Select all that apply.)

Accepted Answer

The answer of The nurse is providing care for a...

Question 11

The nurse is preparing to assist a patient with eating who is recovering from a stroke. Which intervention is appropriate?

Accepted Answer

Checking the patient's mouth periodically for pocketed food is important because patients recovering from a stroke may have difficulty swallowing and may not be aware of food remaining in their mouth, which can increase the risk of aspiration.

Question 12

A patient comes into the emergency department with symptoms of a stroke. Which medication does the nurse expect to be given to the patient if diagnostic testing confirms an ischemic stroke?

Accepted Answer

Tissue-type plasminogen activator (tPA) is the medication of choice for an ischemic stroke because it works by dissolving the clot that is blocking blood flow to the brain, which is the cause of the stroke.

Question 13

The patient is diagnosed with a cerebral vascular accident that has the slowest rate of recovery and the highest probability of causing extensive neurologic deficits. For which type of stroke does the nurse plan care for this patient?

Accepted Answer

Subarachnoid hemorrhage (SAH) often results in extensive neurological deficits and has a slower recovery rate compared to other types of strokes due to the widespread effects of bleeding into the subarachnoid space, increased intracranial pressure, and the potential for hydrocephalus and vasospasm.

Question 14

A patient is admitted from the emergency department to the hospital unit following the diagnosis of an ischemic stroke. The patient did not qualify for tPA therapy. The nurse is aware that which poststroke condition places the patient at greatest risk for deep vein thrombosis (DVT)?

Accepted Answer

Hypercoagulability related to the admitting diagnosis is the poststroke condition that places the patient at greatest risk for deep vein thrombosis (DVT).

Question 15

The nurse is providing care for a patient diagnosed with an ischemic stroke on the left side of the brain. The nurse notices that the patient does not easily locate items placed at the bedside. In which area does the nurse place items for easy location?

Accepted Answer

An ischemic stroke on the left side of the brain can lead to right-sided weakness and possibly neglect of the right visual field. Placing items on the right side can help the patient more easily locate and reach for them, compensating for the neglect.

Question 16

The nurse is assisting with the care of a patient following an ischemic stroke who does not qualify for tPA therapy. The patient's current blood pressure is 190/110 mm Hg. For which reason will the patient's hypertension remain untreated?

Accepted Answer

Permissive hypertension is a strategy used in the acute phase of an ischemic stroke to help maintain cerebral perfusion pressure and potentially salvage brain tissue that is at risk but not yet infarcted. This approach allows for a higher than normal blood pressure to ensure blood flow to areas of the brain affected by the stroke.

Question 17

The nurse is providing care for a patient recovering from a right hemisphere infarct who now exhibits unilateral neglect. Which nursing intervention is most important at promoting safety for this patient?

Accepted Answer

Teaching the patient to purposefully check the location of the left limbs helps the patient become more aware of the neglected side, reducing the risk of injury and promoting safety.

Question 18

A patient comes into the emergency department with unilateral paralysis, aphasia, and inability to follow directions. Which emergency management by the health care provider (HCP) is unexpected by the nurse?

Accepted Answer

The answer of A patient comes into the emergency department...

Question 19

The nurse is assisting the registered nurse (RN) in providing care for a patient who is recovering from a stroke. Which assigned intervention by the RN will the nurse question?

Accepted Answer

Observing the patient performing active range of motion (ROM) on the affected side might not be appropriate depending on the patient's condition post-stroke. Active ROM exercises on the affected side could potentially cause harm if the patient's muscle strength and coordination are not adequately assessed and monitored. The other options are standard care practices for stroke recovery.

Question 20

A patient arrives at the emergency department and states, "Something is wrong. I just don't feel right." Which objective data causes the nurse to suspect the patient is experiencing some type of stroke?

Accepted Answer

Ataxia, or the lack of muscle coordination, can be a sign of a stroke, especially if it occurs suddenly. This can affect the patient's ability to walk or perform tasks that require fine motor skills, indicating a potential neurological impairment such as a stroke.

Quiz 49: Nursing Care of Patients With Cerebrovascular Disorders