Question 1

The nurse is caring for a client who has had a subarachnoid hemorrhage and is being cared for in the intensive care unit. Which of the following information about vasospasms should the nurse be aware of when planning care?

Accepted Answer

Peak time for vasospasm to occur is 7-10 days after the initial bleed. In addition, release of endothelin (a potent vasoconstrictor) may play a major role in the induction of cerebral vasospasm after SAH rather than helping to relieve it. The BP is within normal limits.
RBCs in the CSF are a typical clinical manifestation of a subarachnoid hemorrhage.

Question 2

The nurse is teaching a client's family about immediate stroke care. Which of the following information should the nurse include in teaching plan?

Accepted Answer

Elevated BP is common immediately after a stroke and may be a protective response to maintain cerebral perfusion. Immediately following ischemic stroke, use of drugs to lower BP is recommended only if BP is markedly increased (mean arterial pressure >130 mm Hg or systolic BP >220 mm Hg). Withholding medications can be dangerous; medications do not have to be given by the oral route.

Question 3

The nurse is receiving a change-of-shift report. Which of the following clients 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 also should be given as quickly as possible, but timing of the medications is not as critical.

Question 4

The nurse is caring for a client who had a stroke and is in the acute phase of care. Which of the following systems is priority?

Accepted Answer

During the acute phase following a stroke, management of the respiratory system is a nursing priority. Stroke patients are particularly vulnerable to respiratory problems as it has been shown that respiratory muscle strength decreases following stroke. Advancing age and immobility increase the risk for atelectasis and pneumonia.

Question 5

The nurse is admitting a client who began experiencing right-sided arm and leg weakness to the emergency department. In which order should the nurse implement these actions included in the stroke protocol? (Select all that apply.)

Accepted Answer

The initial actions should be those that help with circulation, airway, and breathing. Baseline neurological assessments should be done next. A CT scan will be needed to rule out hemorrhagic stroke before tPA can be administered.

Question 6

The nurse is caring for a client with sudden-onset right-sided weakness who has a CT scan and is diagnosed with an intracerebral hemorrhage. Which of the following information about the client is most important to communicate to the health care provider?

Accepted Answer

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 client is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the client but has no immediate effect on the client'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 7

The nurse is admitting a client with right-sided weakness that started 90 minutes earlier to the emergency department and all these diagnostic tests are prescribed. Which of the following tests 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 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.

Question 8

The nurse is caring for a client with a stroke who has progressive development of neurological deficits with increasing weakness and decreased level of consciousness (LOC). Which of the following nursing diagnoses has the highest priority for the client?

Accepted Answer

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

Question 9

The nurse is admitting a client with left-sided hemiparesis who has arrived by ambulance to the emergency department. Which of the following actions 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 CABs (circulation, airway, breathing) are completed.

Quiz 60: Nursing Management Stroke