Question 1

A 63-year-old patient who began experiencing right 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 a space between each answer choice [A,B,C,D].) A) Obtain computed tomography (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.

Accepted Answer

The answer of A 63-year-old patient who began experiencing right...

Question 2

A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage.Which information about the patient is most important to communicate to the health care provider?

Accepted Answer

The use of warfarin probably 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.

Question 3

Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness (LOC).Which nursing diagnosis do they determine has the highest priority for the patient?

Accepted Answer

Protection of the airway is the priority of nursing care for a patient having an acute stroke.The other diagnoses are also appropriate,but interventions to prevent aspiration are the priority at this time.

Question 4

Which information about the patient who has had a subarachnoid hemorrhage is most important to communicate to the health care provider?

Accepted Answer

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.

Question 5

The home health nurse is caring for an 81-year-old who had a stroke 2 months ago.Based on information shown in the accompanying figure from the history,physical assessment,and physical therapy/occupational therapy,which nursing diagnosis is the highest priority for this patient?

Accepted Answer

The spouse's household and patient care responsibilities,in combination with chronic illnesses,indicate a high risk for caregiver role strain.The nurse should further assess the situation and take appropriate actions.The data about the control of the patient's diabetes indicates that ineffective health maintenance and risk for unstable blood glucose are not priority concerns at this time.Because the patient is able to ambulate with a cane,the nursing diagnosis of impaired transfer ability is not supported.

Question 6

A 70-year-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department.Which action should the nurse take first?

Accepted Answer

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,and circulation)are completed.

Question 7

The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting.Which assessment information is of most concern to the nurse?

Accepted Answer

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.

Question 8

The nurse is caring for a patient who has been experiencing stroke symptoms for 60 minutes.Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)?

Accepted Answer

Administration of subcutaneous medications is included in LPN/LVN education and scope of practice.The other actions require more education and scope of practice and should be done by the registered nurse (RN).

Question 9

A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered.Which test should be done first?

Accepted Answer

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 less 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.

Question 10

After receiving change-of-shift report on the following four patients,which patient should the nurse see first?

Accepted Answer

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 should also be given as quickly as possible,but timing of the medications is not as critical.

Quiz 58: Nursing Management: Stroke