NCLEX med surg stroke

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Stroke Questions: NCLEX Style

10 terms superCandace32 Preview stroke nclex questions 27 terms grau002Preview Spinal Cord Injury NCLEX 26 terms ET0003Preview Seizure 12 terms mur In promoting health maintenance for prevention of strokes, the nurse understands that the highest risk for the most common type of stroke is present in

• African Americans
• women who smoke

c.individuals with hypertension and diabetes

• those who are obese with high dietary fat intake

C: Individuals with hypertension and diabetes- The highest risk factors for

thrombotic stroke are hypertension and diabetes. African Americans have a higher risk for stroke than do white persons but probably because they have a greater incidence of hypertension. Factors such as obesity, diet high in saturated fats and cholesterol, cigarette smoking, and excessive alcohol use are also risk factors but carry less risk than hypertension.A thrombus that develops in a cerebral artery does not always cause a loss of neurologic function because

• the body can dissolve the atherosclerotic plaques as

they form

• some tissues of the brain do not require constant

blood supply to prevent damage

• circulation through the circle of Willis may provide

blood supply to the affected area of the brain

• neurologic deficits occur only when major arteries are

occluded by thrombus formation around an atherosclerotic plaque

C: Circulation through the circle of Willis may provide blood supply to the

affected area of the brain.The communication between cerebral arteries in the circle of Willing provides a collateral circulation, which may maintain circulation to an area of the brain if its original blood supply is obstructed. ALl areas of the brain require constant blood supply, and atherosclerotic plaques are not readily reversed. Neurologic deficits can result from ischemia cause by many factors.

A patient comes to the emergency department immediately after experiencing numbness of the face and an inability to speak, but while the patient awaits examination, the symptoms disappear and the patient request discharge. The nurse stresses that it is important for the patient to be evaluated primarily because

• the patient has probably experienced an asymptomatic

lacunar stroke

• the symptoms are likely to return and progress to

worsening neurologic deficit in the next 24 hours

• neurologic deficits that are transient occur most often

as a result of small hemorrhages that clot off

• the patient has probably experienced a transient

ischemic attack (TIA), which is a sign of progressive cerebral vascular disease D: The patient has probably experienced a transient ischemic attack (TIA), which is a sign of progressive cerebral vascular disease- A TIA is a temporary focal loss of neurologic function caused by ischemia of an area of the brain, usually lasting only about 3 hours. TIAs may be due to microemboli from heart disease or carotid or cerebral thrombi and are a warning of progressive disease. Evaluation is necessary to determine the cause of the neurologic deficit and provide prophylactic treatment if possible.The neurologic functions that are affected by a stroke are primarily related to

• the amount of tissue area involved
• the rapidity of onset of symptoms
• the brain area perfused by the affected artery
• the presence or absence of collateral circulation

C: The brain area perfused by the affected artery- clinical manifestation of altered neurologic function differ, depending primarily on the specific cerebral artery involved and the area of the brain that is perfused by the artery. The degree of impairment depends on rapidity of onset, the size of the lesion, and the presence of collateral circulation.A patient is admitted to the hospital with a left hemiplegia. To determine the size and location and to ascertain whether a stroke is ischemic or hemorrhagic, the nurse anticipates that the health care provider will request a

• CT scan
• lumbar puncture
• cerebral arteriogram
• positron emission tomography (PET)

A: CT scan- A CT scan is the most commonly used diagnostic test to determine the size and location of the lesion and to differentiate a thrombotic stroke from a hemorrhagic stroke. Positron emission tomography (PET) will show the metabolic activity of the brain and provide a depiction of the extent of tissue damage after a stroke. Lumbar punctures are not performed routinely because of the chance of increased intracranial pressure causing herniation. Cerebral arteriograms are invasive and may dislodge an embolism or cause further hemorrhage; they are performed only when no other test can provide the needed information.A carotid endarterectomy is being considered as a treatment for a patient who has had several TIAs. The nurse explains to the patient that this surgery

• is used to restore blood to the brain following an

obstruction of a cerebral artery

• involves intracranial surgery to join a superficial

extracranial artery to an intracranial artery

• involves removing an atherosclerotic plaque in the

carotid artery to prevent an impending stroke

• is sued to open a stenosis in a carotid artery with a

balloon and stent to restore cerebral circulation C: Involves removing an atherosclerotic plaque in the carotid artery to prevent an impending stroke- An endarterectomy is a removal of an atherosclerotic plaque, and plaque in the carotid artery may impair circulation enough to cause a stroke.A carotid endarterectomy is performed to prevent a cerebrovascular accident (CVA), as are most other surgical procedures. An extacranial-intracranial bypass involves cranial surgery to bypass a sclerotic intacranial artery. Percutaneous transluminal angioplasty uses a balloon to compress stenotic areas in the carotid and vertebrobasilar arteries and often includes inserting a stent to hold the artery open.The incidence of ischemic stroke in patients with TIAs and other risk factors is reduced with administration of

• furosemide (Lasix)
• lovastatin (Mevacor)
• daily low dose aspirin
• nimodipine (Nimotop)

C: Daily low dose aspirin- the administration of antiplatelet agents, such as aspirin, dipyridamole (Persantine), and ticlopdipine (Ticlid), reduces the incidence of stroke in those at risk. Anticoagulants are also used for prevention of embolic strokes but increase the risk for hemorrhage. Diuretics are not indicated for stroke prevention other than for their role in controlling BP, and antilipemic agents have bot been found to have a significant effect on stroke prevention. The calcium channel blocker nimodipine is used in patients with subarachnoid hemorrhage to decrease the effects of vasospasm and minimize tissue damage.P.S. I freaking love you and good luck on the final!!

The priority intervention in the emergency department for the patient with a stroke is

• intravenous fluid replacement
• administration of osmotic diuretics to reduce cerebral

edema

• initiation of hypothermia to decrease the oxygen needs

of the brain

• maintenance of respiratory function with a patent

airway and oxygen administration

D: Maintenance of respiratory function with a patent airway and oxygen

administration- the first priority in acute management of the patient with a stroke is preservation of life. Because the patient with a stroke may be unconscious or have a reduced gag reflex, it is most important to maintain a patent airway for the patient and provide oxygen if respiratory effort is impaired. IV fluid replacement, treatment with osmotic diuretics, and perhaps hypothermia may be used for further treatment.A diagnosis of a ruptured cerebral aneurysm has been made in a patient with manifestations of a stroke. The nurse anticipates that treatment options that would be evaluated for the patient include

• hyperventilation therapy
• surgical clipping of the aneurysm
• administration of hyperosmotic agents
• administration of thrombolytic therapy

B: Surgical clipping of they aneurysm- Surgical management with clipping of an

aneurysm to decrease re bleeding and vasospasm is an option for a stroke cause by rupture of a cerebral aneurysm. Placement of coils into the lumens of the aneurysm by intercentional radiologists is increasing in popularity.Hyperventilation therapy would increase vasodilation and the potential for hemorrhage. Thrombolytic therapy would be absolutely contraindicated, and if a vessel is patent, osmotic diuretics may leak into tissue, pulling fluid out of the vessel and increasing edema.During the acute phase of a stroke, the nurse assesses the patient's vital signs and neurologic status every 4 hours. A cardiovascular sign that the nurse would see as the body attempts to increase cerebral blood flow is

• hypertension
• fluid overload
• cardiac dysrhythmias
• S3 and S4 heart sounds

A: Hypertension- The body responds to the vasopasm and a decreased

circulation to the brain that occurs with a stroke by increasing the BP, frequently resulting in hypertension. The other options are important cardiovascular factors to assess, but they do not result from impaired cerebral blood flow.A nursing intervention is indicated for the patient with hemiplegia is

• the use of a footboard to prevent plantar flexion
• immobilization of the affected arm against the chest

with a sling

• positioning the patient in bed with each joint lower

than the joint proximal to it

• having the patient perform passive ROM of the

affected limb with the unaffected limb

D: Having the patient perform passive ROM of the affected limb with the

unaffected limb- active ROM should be initiated on the unaffected side as soon as possible, and passive ROM of the affected side should be started on the first day. Having the patient actively exercise the unaffected side provides the patient with active and passive ROM as needed. Use of footboards is controversial because they stimulate plantar flexion. The unaffected arm should be supported, but immobilization may precipitate a painful shoulder-hand syndrome. The patient should be positioned with each joint higher than the joint proximal to it to prevent dependent edema.A newly admitted patient who has suffered a right sided brain stroke has a nursing diagnosis of disturbed visual sensory perception related to homonymous hemianopsia.Early in the care of the patient, the nurse should

• place objects on the right side within the patient's field

of vision

• approach the patient from the left side to encourage

the patient to turn the head

• place objects on the patient's left side to assess the

patient's ability to compensate

• patch the affected eye to encourage the patient to

turn the head to scan the environment A: Place objects on the right side within the patient's field of vision- the presence of homonymous hemianopia in a patient with right-hemisphere brain damage causes a loss of vision in the left field. Early in the care of the patient, objects should be placed on the right side of the patient in the field of vision, and the nurse should approach the patient from the right side. Later in treatment, patients should be taught to turn the head and scan the environment and should be approached from the affected side to encourage head turning. Eye patches are used if patients have diplopia (double vision).

Four days following a stroke, a patient is to start oral fluids and feedings. Before feeding the patient, the nurse should first

• check the patient's gag reflex
• order a soft diet for the patient
• raise the head of the bed to sitting position
• evaluate the patient's ability to swallow small sips of ice

water A: check the patient's gag reflex- the first step in providing oral feedings for a patient with a stroke is ensuring that the patient has an intact gag reflex because oral feedings will not be provided if gag reflex is impaired. The nurse should then evaluate the patient's ability to swallow ice chips or ice water after placing the patient in an upright position An appropriate food for a patient with a stroke who has mild dysphagia is

• fruit juices
• pureed meat
• scrambled eggs
• fortified milkshakes

C: scrambled eggs- soft foods that provide enough texture, flavor, and bulk to

stimulate swallowing should be used for the patient with dysphasia. Thin liquids are difficult to swallow, and patients may not be able to control them in the mouth. Pureed foods are often too bland and to smooth, and milk products should be avoided because they tend to increase the viscosity of mucus and increase salivation.A patient's wife asks the nurse why her husband did not receive the clot busting medication (tPA) she has been reading about. Her husband is diagnosed with a hemorrhagic stroke. What should the nurse respond?

• He didn't arrive within the time frame for that therapy
• Not every is eligible for this drug. Has he had surgery

lately?

• You should discuss the treatment of your husband with

your doctor

• The medication you are talking about dissolves clots

and could cause more bleeding in your husband's head

D: The medication you are talking about dissolves clots and could cause more

bleeding in your husband's head- tPA dissolves clots and increases the risk for bleeding. It is not used with hemorrhagic strokes. If the patient had a thrombotic/embolic stroke the time frame would be important as well as a history of surgery. The nurse should answer the question as accurately as possible and then encourage the individual to talk with the primary care physician if he or she has further questions.To promote communication during rehabilitation of the patient with aphasia, an appropriate nursing intervention is to

• use gestures, pictures, and music to stimulate patient

responses

• talk about activities of daily living (ADLs) that are

familiar to the patient

• structure statements so that patient does not have to

respond verbally

• use flashcards with simple words and pictures to

promote language recall B: Talk about ADLs that are familiar to the patient- during rehabilitation, the patient with aphasia needs frequent, meaningful verbal stimulation that has relevance for him. Conversation by the nurse and family should address ADLs that are familiar to the patient. Gestures, pictures, and simple statements are more appropriate in the acute phase, when patients may be overwhelmed with verbal stimuli. Flashcards are often perceived by the patient as childish and meaningless.A patient with right hemisphere stroke has a nursing diagnosis of unilateral neglect related to sensory perceptual deficits. During the patient's rehabilitation, it is important for the nurse to

• avoid positioning the patient on the affected side
• place all objects for care on the patient's unaffected

side

• teach the patient to care consciously for the affected

side

• protect the affected side from injury with pillows and

supports C: Teach the patient to care consciously for the affected side- unilateral neglect, or neglect syndrome, occurs when the patient with a stroke is unaware of the affected side of the body, which puts the patient at risk for injury. During the acute phase, the affected side is cared for by the nurse with positioning and support, during rehabilitation the patient is taught to care consciously for and attend to the affected side of the body to protect it from injury. Patients may be positioned on the affected side for up to 30 minutes.