Ch 54 - Stroke

Question 1

CH 54 Brown & Edwards
1. Which modifiable risk factors for stroke would be most important for the nurse to include when planning a community education program?a. Hypertensionb. Hyperlipidemia c. Alcohol consumptiond. Oral contraceptive use

Answer 1

ANS A
a. Hypertension

Hypertension is the single most important modifiable risk factor, but it is still often undetected and inadequately treated. The public is often more aware of hyperlipidemia and oral contraceptive use as risk factors for stroke. Alcohol is also a modifiable risk factor.

Question 2

CH 54 Brown & Edwards
2. The nurse would expect to find what clinical manifestation in a patient admitted with a left-sided stroke?a. Impulsivityb. Impaired speechc. Left-side neglectd. Short attention span

Answer 2

ANS B
b. Impaired speech

Clinical manifestations of left-sided brain damage include right hemiplegia, impaired speech/language, impaired right/left discrimination, and slow and cautious performance. Impulsivity, left-sided neglect, and short attention span are all manifestations of right-sided brain damage.

Question 3

CH 54 Brown & Edwards
3. The nurse is discharging a patient admitted with a transient ischemic attack (TIA). For which medications might the nurse expect to provide discharge instructions (select all that apply)?a. Clopidogrel (Plavix)b. Enoxaparin (Lovenox) c. Dipyridamole (Persantine)d. Enteric-coated aspirin (Ecotrin)e. Tissue plasminogen activator (tPA)

Answer 3

ANS: A, C, D

a. Clopidogrel (Plavix)
c. Dipyridamole (Persantine)
d. Enteric-coated aspirin (Ecotrin)

Aspirin is the most frequently used antiplatelet agent. Other drugs to prevent clot formation include clopidogrel (Plavix), dipyridamole (Persantine), ticlopidine (Ticlid), combined dipyridamole and aspirin (Aggrenox), and anticoagulant drugs, such as oral warfarin (Coumadin). Tissue plasminogen activator is a fibrinolytic medication used to treat ischemic stroke not prevent TIAs or strokes.

Question 4

CH 54 Brown & Edwards
4. Which intervention is most appropriate when communicating with a patient suffering from aphasia following a stroke?a. Present several thoughts at once so that the patient can connect the ideas.b. Ask open-ended questions to provide the patient the opportunity to speak.c. Finish the patient’s sentences to minimize frustration associated with slow speech.d. Use simple, short sentences accompanied by visual cues to enhance comprehension.

Answer 4

ANS: D
d. Use simple, short sentences accompanied by visual cues to enhance comprehension.

When communicating with a patient with aphasia, the nurse should present one thought or idea at a time. Ask questions that can be answered with a “yes,” “no,” or simple word. Use visual cues and allow time for the individual to comprehend and respond to conversation.

Question 5

CH 54 Brown & Edwards
5. Computed tomography (CT) of a 68-year-old male patient’s head reveals that he has experienced a hemorrhagic stroke. What is the priority nursing intervention in the emergency department?a. Maintenance of the patient’s airwayb. Positioning to promote cerebral perfusionc. Control of fluid and electrolyte imbalancesd. Administration of tissue plasminogen activator (tPA)

Answer 5

ANS: A
a. Maintenance of the patient’s airway

Maintenance of a patent airway is the priority in the acute care of a patient with a hemorrhagic stroke. It supersedes the importance of fluid and electrolyte imbalance and positioning. tPA is contraindicated in hemorrhagic stroke.

Question 6

CH 54 Brown & Edwards
6. A female patient has left-sided hemiplegia following an ischemic stroke that she experienced 4 days earlier. How should the nurse best promote the health of the patient’s integumentary system?a. Position the patient on her weak side the majority of the time.b. Alternate the patient’s positioning between supine and side-lying.c. Avoid the use of pillows in order to promote independence in positioning.d. Establish a schedule for the massage of areas where skin breakdown emerges.

Answer 6

ANS: B
b. Alternate the patient’s positioning between supine and side-lying.

A position change schedule should be established for stroke patients. An example is side-back-side, with a maximum duration of 2 hours for any position. The patient should be positioned on the weak or paralyzed side for only 30 minutes. Pillows may be used to facilitate positioning. Areas of skin breakdown should never be massaged.

Question 7

CH 54 Brown & Edwards
7. Which sensory-perceptual deficit is associated with left-sided stroke (right hemiplegia)? a. Overestimation of physical abilitiesb. Difficulty judging position and distancec. Slow and possibly fearful performance of tasksd. Impulsivity and impatience at performing tasks

Answer 7

ANS: C
c. Slow and possibly fearful performance of tasks

Patients with a left-sided stroke (right hemiplegia) commonly are slower in organization and performance of tasks and may have a fearful, anxious response to a stroke. Overconfidence, spatial disorientation, and impulsivity are more commonly associated with a right-sided stroke.

Question 8

CH 54 Brown & Edwards
8. The female patient has been brought to the ED with a sudden onset of a severe headache that is different from any other headache she has had previously. When considering the possibility of a stroke, which type of stroke should the nurse know is most likely occurring?a. TIA b. Embolic stroke c. Thrombotic stroke d. Subarachnoid hemorrhage

Answer 8

ANS: D
d. Subarachnoid haemorrhage

Headache is common in a patient who has a subarachnoid hemorrhage or an intracerebral hemorrhage. A TIA is a transient loss of neurologic function usually without a headache. A headache may occur with an ischemic embolic stroke, but severe neurologic deficits are the initial symptoms. The ischemic thrombotic stroke manifestations progress in the first 72 hours as infarction and cerebral edema increase.

Question 9

CH 54 Brown & Edwards
9. The patient with diabetes mellitus has had a right-sided stroke. Which nursing intervention should the nurse plan to provide for this patient related to expected manifestations of this stroke?a. Safety measuresb. Patience with communicationc. Mobility assistance on the right sided. Place food in the left side of patient’s mouth.

Answer 9

ANS: A
a. Safety measures

A patient with a right-sided stroke has spatial-perceptual deficits, tends to minimize problems, has a short attention span, is impulsive, and may have impaired judgment. Safety is the biggest concern for this patient. Hemiplegia occurs on the left side of this patient’s body. The patient with a left-sided stroke has hemiplegia on the right, is more likely to have communication problems, and needs mobility assistance on the right side with food placed on the left side if the patient needs to be fed after a swallow evaluation has taken place.

Question 10

CH 54 Brown & Edwards
10. The nurse is planning psychosocial support for the patient and family of the patient who suffered a stroke. What factor will most likely have the greatest impact on positive family coping with the situation? a. Specific patient neurologic deficitsb. The patient’s ability to communicatec. Rehabilitation potential of the patientd. Presence of complications of a stroke

Answer 10

ANS: C
c. Rehabilitation potential of the patient

Although a patient’s neurologic deficit might initially be severe after a stroke, the ability of the patient to recover is most likely to positively impact the family’s coping with the situation. Providing explanations and emotional support beginning in the acute phase through the rehabilitation phase will facilitate coping. Emphasizing successes will offer the most realistic hope for the patient’s rehabilitation and helps maintain hope for the patient’s future abilities.