Med Surg Lewis - Stroke, Seizure NCLEX Review, NCLEX med surg stroke, PVD NCLEX questions, 6270 Exam #2

Med Surg Lewis - Stroke, Seizure NCLEX Review, NCLEX med surg stroke, PVD NCLEX questions, 6270 Exam #2 5.0 (2 reviews) Students also studied Terms in this set (207) Science MedicineNursing Save

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180 terms Rose4849Preview Seizures NCLEX 12 terms murkacatPreview NCLEX Style Practice Questions Bur...100 terms akrrissman84Preview NCLEX 36 terms Sha Which sensory-perceptual deficit is associated with left- sided stroke (right hemiplegia)?

• Overestimation of physical abilities
• Difficulty judging position and distance
• Slow and possibly fearful performance of tasks
• Impulsivity and impatience at performing tasks
• 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.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

• Embolic stroke
• Thrombotic stroke
• Subarachnoid hemorrhage
• Subarachnoid hemorrhage

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.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

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.

The nurse in a primary care provider's office is assessing several patients today. Which patient is most at risk for a stroke?

• A 92-year-old female who takes warfarin (Coumadin)

for atrial fibrillation.

• A 28-year-old male who uses marijuana after

chemotherapy to control nausea.

• A 42-year-old female who takes oral contraceptives

and has migraine headaches.

• A 72-year-old male who has hypertension and

diabetes mellitus and smokes tobacco.

• A 72-year-old male who has hypertension and diabetes mellitus and smokes

tobacco.Stroke risk increases after 65 years of age. Strokes are more common in men.Hypertension is the single most important modifiable risk factor for stroke.Diabetes mellitus is a significant stroke risk factor; and smoking nearly doubles the risk of a stroke. Other risk factors include drug abuse (especially cocaine), high- dose oral contraception use, migraine headaches, and untreated heart disease such as atrial fibrillation.Which characteristic of a patient's recent seizure is consistent with a focal seizure?

• The patient lost consciousness during the seizure.
• The seizure involved lip smacking and repetitive

movements.

• The patient fell to the ground and became stiff for 20

seconds.

• The etiology of the seizure involved both sides of the

patient's brain.

• The seizure involved lip smacking and repetitive movements.

The most common complex focal seizure involves lip smacking and automatisms (repetitive movements that may not be appropriate). Loss of consciousness, bilateral brain involvement, and a tonic phase are associated with generalized seizure activity.The nurse provides information to the caregiver of a 68- year-old man with epilepsy who has tonic-clonic seizures.Which statement, if made by the caregiver, requires further teaching?

• "It is normal for a person to be sleepy after a seizure."
• "I should call 911 if breathing stops during the seizure."
• "The jerking movements may last for 30 to 40

seconds."

• "Objects should not be placed in the mouth during a

seizure."

• "I should call 911 if breathing stops during the seizure."

Caregivers do not need to call an ambulance or send a person to the hospital after a single seizure unless the seizure is prolonged, another seizure immediately follows, or extensive injury has occurred. Altered breathing is a clinical manifestation of a tonic-clonic seizure. Contact emergency medical services (or call 911) if breathing stops for more than 30 seconds. No objects (e.g., oral airway, padded tongue blade) should be placed in the mouth. Lethargy is common in the postictal phase of a seizure. Jerking of the extremities occurs during the clonic phase of a tonic-clonic seizure. The clonic phase may last 30 to 40 seconds.The nurse is caring for a group of patients on a medical unit. After receiving report, which patient should the nurse see first?

• A 42-year-old patient with multiple sclerosis who was

admitted with sepsis

• A 72-year-old patient with Parkinson's disease who has

aspiration pneumonia

• A 38-year-old patient with myasthenia gravis who

declined prescribed medications

• A 45-year-old patient with amyotrophic lateral

sclerosis who refuses enteral feedings

• A 38-year-old patient with myasthenia gravis who declined prescribed

medications Patients with myasthenia gravis who discontinue pyridostigmine (Mestinon) will develop a myasthenic crisis. Myasthenia crisis results in severe muscle weakness and can lead to a respiratory arrest.

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.

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.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.