Question 1

The nurse is assessing a newly admitted older patient for modifiable risk factors for stroke development.The nurse would include teaching about which findings? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

Accepted Answer

Modifiable risk factors for stroke development include hypertension (A), previous hospitalizations for dehydration (B) may indicate poor fluid intake and an increased risk for clot formation, and hypercholesterolemia (E). Drinking alcohol (C) in moderation may actually have a protective effect against stroke, while smokeless tobacco (D) use is a non-modifiable risk factor.

Question 2

When developing a teaching plan for a patient who had an embolic stroke,the nurse considers which history as a significant risk factor?

Accepted Answer

Atrial fibrillation is a significant risk factor for embolic stroke as the irregular heartbeat can allow blood clots to form in the heart and travel to the brain. Hypertension, use of anticoagulants, and a history of atherosclerosis can also be risk factors, but atrial fibrillation is the most significant in terms of embolic stroke.

Question 3

A patient who has been admitted with symptoms of stroke is to have a CT scan.What rationale for this testing would the nurse provide to the patient and family?

Accepted Answer

The CT scan can differentiate hemorrhagic (bleeding) from ischemic (blockage) causes of the stroke, which is important in guiding appropriate treatment. CT scans do not evaluate cerebral circulation or brain swelling, although they may help pinpoint the area of the brain affected by the stroke.

Question 4

The nurse is triaging a patient who just presented to the emergency department.Which cluster of assessment findings would the nurse evaluate as indicating the greatest possibility that this patient is having a stroke?

Accepted Answer

The cluster of assessment findings in option B, difficulty with balance, hemianopsia (blindness in half of the visual field of one or both eyes), and hemiparesis (weakness on one side of the body), are highly indicative of a stroke.

Question 5

When planning nursing care for a patient with a stroke,the nurse should consider which primary goal of medical management?

Accepted Answer

The primary goal of medical management for a patient with a stroke is to restore cerebral blood flow and limit the size of the infarcted area of the brain. This can be achieved with thrombolytic therapy, anticoagulation therapy, and other interventions aimed at improving blood flow to the affected area. Keeping the blood pressure under control and transferring the patient for rehabilitation are important aspects of stroke care, but they are not the primary goals of medical management. Reestablishing blood flow to the infarcted area surgically may be necessary in some cases, but it is not a primary goal of medical management.

Question 6

The nurse is instructing a patient on stroke prevention.Which patient statement would the nurse evaluate as indicating understanding of the presence of a nonmodifiable risk factor for stroke development?

Accepted Answer

Nonmodifiable risk factors for stroke development include ethnicity, age, gender, and family history. Statement A indicates a family history of hypertension, which is a modifiable risk factor. Statements C and D refer to modifiable risk factors for stroke (smoking and high cholesterol), which can be addressed through behavior change. Statement B correctly identifies ethnicity as a nonmodifiable risk factor.

Question 7

A patient is diagnosed with bleeding into the cerebellum.The nurse would prepare this patient for which medical intervention?

Accepted Answer

Bleeding into the cerebellum is a medical emergency as it can lead to increased pressure on the brain and potentially life-threatening complications. The most effective treatment for this condition is surgical intervention to remove the blood from the cerebellum, also known as a craniotomy. Angioplasty and stent placement are typically used to treat blockages in blood vessels, which is not the case in this scenario. Aggressive diuretic therapy may be used in some cases to reduce cerebral edema, but it is not the primary treatment for bleeding into the cerebellum.

Question 8

Which nursing interventions are indicated when providing care for a patient recovering from right carotid endarterectomy? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

Accepted Answer

The answer of Which nursing interventions are indicated when providing...

Question 9

A patient is receiving tissue plasminogen activator (tPA)for the treatment of an ischemic stroke.Which nursing interventions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

Accepted Answer

Monitoring for deterioration of neurological status is essential when a patient is receiving tPA for treatment of an ischemic stroke. This medication can cause bleeding in the brain, which can lead to worsened neurologic symptoms. Inserting a nasogastric tube for nutritional support and repositioning every 15 minutes are not indicated interventions for a patient receiving tPA. Monitoring for renal stone formation is also not relevant to tPA administration.

Question 10

A patient comes into the emergency department with complaints of partial loss of vision in one eye,numbness and tingling of the arm and leg,and dizziness.Which additional information should the nurse initially seek from the patient?

Accepted Answer

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

Question 11

A patient with cerebral infarction is experiencing an acceleration of symptoms indicating death of cerebral tissue.The nurse would explain this acceleration as due to which pathophysiology?

Accepted Answer

Increased concentration of sodium, chloride, and calcium in the brain cells can lead to an influx of water and ultimately cause cellular swelling and death. This is known as cytotoxic edema, which is a common occurrence in cerebral infarction.

Question 12

Which assessment finding increases the concern that a patient with a cerebral vascular accident would aspirate?

Accepted Answer

Continuous clearing of the throat suggests the presence of oropharyngeal dysphasia, which increases the risk for aspiration.

Question 13

The nurse is planning care for a patient with a thrombotic stroke in the distribution of the right middle cerebral artery.Which patient problem is the priority for care in the acute phase of this disease process?

Accepted Answer

In the acute phase of thrombotic stroke, the priority for care is to restore circulation to the brain. If circulation is not restored, the brain tissue will not receive adequate oxygen and nutrients and will be damaged. This can result in permanent disability or death. Therefore, restoring adequate perfusion is the most important priority for care. While nutrition, paralysis, and adaptive capacity are all important concerns, they are secondary to maintaining cerebral perfusion.

Question 14

A patient with spasticity of the upper extremity after a stroke asks why a sling is not used to support the arm.Which rationale should the nurse provide?

Accepted Answer

Using a sling can reinforce the spasticity and hinder the patient from actively using and exercising the affected arm, which can lead to contracture. Encouraging active range of motion exercises and functional use of the arm is more beneficial for long-term recovery.

Question 15

A patient is recovering from surgery to clip an aneurysm.The nurse would anticipate managing which interventions to help prevent cerebral vasospasm?

Accepted Answer

Intravenous fluid augmentation is necessary to maintain adequate hydration and prevent cerebral vasospasm, as it increases cerebral blood flow and prevents hyperviscosity of blood. Options A, B, and C are not appropriate interventions for preventing cerebral vasospasm.

Question 16

Which goal would the nurse rank as priority for a patient with stroke-related sensory perception alterations?

Accepted Answer

Safety is always a top priority in nursing care, especially for patients with altered sensations. The patient and caregivers discussing methods to avoid hazards in the environment would help prevent any further injuries or accidents. While the other goals are important, they are secondary to ensuring the patient's safety.

Question 17

Diagnostic testing reveals that a patient has areas of cerebral focal infarctions.The nurse plans care with the realization that which outcome is likely?

Accepted Answer

Focal cerebral infarctions, also known as strokes, result from decreased blood flow to a specific area of the brain causing brain cell damage or death. The outcome will depend on the location and extent of the infarctions, but it is possible for symptoms to improve with treatment such as medication and/or rehabilitation. However, it is unlikely for the patient to deteriorate into multiple system organ failure or for the infarctions to extend into the brainstem. The progression of symptoms will also depend on the severity and location of the infarctions.

Question 18

A patient,admitted with syncope,is diagnosed with an 80% stenosis of the left carotid artery.In addition to assessing the patient's speech,the nurse should focus the assessment on the presence or development of which other findings?

Accepted Answer

The left carotid artery supplies blood to the left side of the brain, which controls the right side of the body. Therefore, an 80% stenosis of the left carotid artery could lead to right-sided hemineglect, sensory, and motor loss due to reduced blood flow and oxygen supply to the brain.

Question 19

The nurse is providing community education regarding stroke.Which information should be included? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

Accepted Answer

These choices are correct because stroke is caused by interruption of blood flow to the brain, it is the fifth-leading cause of death in the United States, rapid recognition of stroke symptoms can help decrease poor outcomes, and stroke causes neurological defects. Choice C is incorrect because stroke usually does not occur simultaneously with myocardial infarction (MI).

Question 20

A patient had a stroke that resulted in Broca's aphasia.What instructions should the nurse provide when teaching the family how to communicate with this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

Accepted Answer

C) Asking "yes-no" questions simplifies the communication process, making it easier for the patient to respond despite difficulties with speech production. E) Giving the patient time to search for words respects their effort to communicate and acknowledges that while their speech production is impaired, their cognitive abilities to understand language may remain intact.

Quiz 18: Acute Stroke Injury

The nurse is assessing a newly admitted older patient for modifiable risk factors for stroke development.The nurse would include teaching about which findings? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.