Ischemic Stroke NCLEX Style questions(NR 341 N.R.)

Ischemic Stroke NCLEX Style questions(NR 341 N.R.) 4.5 (2 reviews) Students also studied Terms in this set (8) Save NCLEX med surg stroke 36 terms Shauna_Wiberg Preview Spinal Cord Injury NCLEX 26 terms ET0003Preview

Stroke Questions: NCLEX Style

10 terms superCandace32 Preview stroke 27 terms gra 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 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 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.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 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.Aspirin is ordered for a patient who is admitted with a possible stroke. Which information obtained during the admission assessment indicates that the nurse should consult with the health care provider before giving the aspirin?

• The patient has atrial fibrillation.
• The patient has dysphasia.
• The patient states, "I suddenly developed a terrible

headache."

• The patient has a history of brief episodes of right

hemiplegia.

• The patient states, "I suddenly developed a terrible headache"

A sudden-onset headache is typical of a hemorrhage and aspirin is contraindicated

The physician orders Alteplase (Activase) for a 58-year- old man diagnosed with an acute ischemic stroke. Which nursing action is most appropriate?

• Administer the medication by an IV route at 15 mL/hr

for 24 hours.

• Insert two or three large-bore IV catheters before

administering the medication.

• If gingival bleeding occurs, discontinue the medication

and notify the physician.

• Reduce the medication infusion rate for a systolic

blood pressure above 180 mm Hg.

• Insert two or three large-bore IV catheters before administering the

medication.

Rationale:

Before giving Alteplase, the nurse should start two or three large bore IVs.Bleeding is a major complication with fibrinolytic therapy, and venipunctures should not be attempted after Alteplase is administered. Altepase is administered IV with an initial bolus dose followed by an infusion of the remaining medication within the next 60 minutes. Gingival bleeding is a minor complication and may be controlled with pressure or ice packs. Control of blood pressure is critical prior to Altepase administration and for the following 24 hours. Before administering Altepase, a systolic pressure above 180 mm Hg or diastolic pressure above 110 mm Hg requires aggressive blood pressure treatment to reduce the risk of cerebral hemorrhage.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?

• Safety measures
• Patience with communication
• Mobility assistance on the right side
• Place food in the left side of patient's mouth.
• Safety measures

Rationale:

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.