Stroke

The ED nurse is completing the admission assessment. Nancy is alert but struggles to answer questions. When she attempts to talk, she slurs her speech and appears very frightened. Which additional clinical manifestations should the nurse expect to find if Nancy’s symptoms have been caused by a brain attack (stroke)?
A. Difficulty swallowing
B. Decreased bowel sounds
C. A carotid bruit
D. Elevated blood pressure
E. Hyperreflexic deep tendon reflexes
A. Difficulty swallowing
– Difficulty swallowing can accompany a brain attack, placing the client at risk for aspiration.
C. A carotid bruit
– The carotid artery (artery to the brain) is narrowed in clients with a brain attack (stroke). A bruit is an abnormal sound heard on auscultation resulting from interference with normal blood flow.
D. Elevated blood pressure
– When a client has a brain attack (stroke), the blood pressure will often respond by going up. Increased BP is a sign of increased intracranial pressure.
The ED physician has completed an assessment. Gail is sitting at the bedside while the ED nurse continues to assess Nancy every 15 minutes. Which assessment finding warrants immediate intervention by the nurse?
A. Nancy has a negative Babinski’s reflex bilaterally
B. Nancy only responds to a painful stimuli
C. Nancy’s Glasgow Coma Scale (GCS) score increases
D. Nancy’s bilateral grip strength is unequal
B. Nancy only responds to painful stimuli
– This decrease in responsiveness warrants immediate intervention by the nurse, indicating a worsening condition (increased intracranial pressure).
Due to her deteriorating condition, Nancy is immediately referred to the neurologist. The ED nurse realizes that Nancy has probably suffered a left-sided brain attack. Which clinical manifestation further supports this assessment?
A. Spatial-perceptual deficits.
B. Visual field deficit on the left side
C. Paresthesia of the left side
D. Global aphasia
D. Global aphasia
-Global aphasia refers to difficulty speaking, listening, and writing. Symptoms vary from person to person. Aphasia may occur secondary to any brain injury involving the left hemisphere.
The neurologist writes a diagnosis of “Suspected brain attack” and prescribes a non contrast computed tomography (CT) scan STAT. Which nursing intervention should the nurse implement when preparing Nancy and her daughter for this procedure?
A. Explain to the daughter that her mother will have to remain still throughout the CT scan
B. Determine if the client has any allergies to iodine
C. Provide an explanation of relaxation exercises prior to the procedure
D. Premedicate the client to decrease pain prior to having the procedure
A. Explain to the daughter that her mother will have to remain still throughout the CT scan.
-Because head motion will distort the images, Nancy will have to remain still throughout the procedure. Since Nancy has decreased LOC, she may require head support to accomplish this.
The neurologist also prescribes a magnetic resonance imaging (MRI) of the head STAT. Which data warrants immediate intervention by the nurse concerning this diagnostic test?
A. Allergy to shellfish
B. History of atrial fibrillation
C. Right hip replacement
D. Elevated blood pressure
C. Right hip replacement
-The magnetic field generated by the MRI is so strong that metal-containing items are strongly attracted to the magnet. Because the hip joint is made of metal, a lead shield must be used during the procedure.
Nancy is transferred to the Intermediate Care Unit after the MRI is completed. She has a 20 gauge saline lock in her right forearm and an 18 French indwelling (Foley) catheter. Gail is sitting by her mother’s bed. The nurse asks Gail if there is anyone that can be called so she won’t be alone. She informs the nurse that she is an only child and her father died years ago. Gail states, “I don’t understand what a brain attack is. The healthcare provider told me my mother is in serious condition and they are going to run several tests. I just don’t know what’s going on. What happened to my mother?” Which response is best by the nurse?
A. “How do you feel about what the healthcare provider said?”
B. “Your mother has had a stroke, and the blood supply to the brain has been compromised.”
C. “I will call the healthcare provider so he/she can talk to you about your mother’s serious condition.”
D. “I am sorry, but what happened to your mother is confidential and I cannot give you any information.”
B. “Your mother has had a stroke, and the blood supply to the brain has been compromised.”
-The nurse has the knowledge, and the responsibility, to explain Nancy’s condition to Gail.
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Gail starts to cry and states, “Mom was just fine last week when we went out to eat and to a show. I love my mom so much, and I am so scared. She is all I have.” How should the nurse respond?
A. “I am sure everything will be all right.”
B. “I will notify the chaplain to come and sit with you so you won’t be alone.”
C. “I know this is scary for you. Would you like to sit and talk?”
C. “I am sure your mother knows you are here. Just keep talking to her.”
C. “I know this is scary for you. Would you like to sit and talk?
-This therapeutic response provides acknowledgment of Gail’s fears, and the nurse offers to take time to discuss the situation.
With a diagnosis of a brain attack (stroke), which priority intervention should the nurse include in Nancy’s plan of care?
A. Monitor INR daily
B. Assess neurological status every shift
C. Keep the head of the bed elevated
D. Evaluate platelet levels daily
C. Keep the head of the bed elevated
– Maintaining a patent airway is essential to support oxygenation and cerebral perfusion. Elevating the head of the bed 30 degrees aids in preventing the tongue from falling backward and obstructing the airway.
The nurse continues to monitor Nancy’s condition closely. Which finding would require immediate intervention by the nurse?
A. Nancy’s pulse oximeter reading is greater than 95%
B. Nancy’s serum potassium level is 3.9 mEq/L
C. Nancy’s telemetry shows normal sinus rhythm with occasional premature ventricular contractions
D. Nancy’s cardiac output is less than 4 L/min
D. Nancy’s cardiac output is less than 4 L/min
– The normal range for cardiac output to ensure cerebral blood flow and oxygen delivery is 4 to 8 L/min.
Though Nancy’s SaO2 potassium level, and telemetry readings are within normal limits for her age, her cardiac output is low. Which nursing interventions would be priority at this time?
A. Monitor capillary refill every 2-4 hours
B. Monitor level of consciousness
C. Monitor vital signs every shift
D. Strict intake and output
E. Contact physician
A. Monitor capillary refill every 2-4 hours
– Decreased cardiac output would affect tissue perfusion, reflected in a capillary refill of greater than 3 seconds.
B. Monitor level of consciousness
– With a decreased cardiac output, cerebral perfusion will be affected. This can be reflected in a further decreased level of consciousness.
D. Strict intake and output
– The kidneys use 25% of cardiac output, so when cardiac output is decreased, the kidneys may start failing. Close monitoring is essential.
E. Contact physician
– The physician needs to be notified regarding decreased cardiac output to decide whether to initiate IV fluids if hypovolemia is an issue and to determine other medical interventions.
As the nurse assesses Nancy, Gail asks, “Why isn’t my mother a candidate for thrombolytic therapy?”
A. “Since your mother was alert on admission, she is not a candidate to receive this medication.
B. “I think that is something you should discuss with your mother’s healthcare provider.”
C. “tPA is usually not administered to anyone older than 65 years.”
D. “She is not a candidate because of therapeutic time constraints related to this medication.”
D. “She is not a candidate because of therapeutic time constraints related to this medication.”
– Thrombolytic therapy is contraindicated in clients with symptom onset longer than 3 hours prior to admission. Nancy had symptoms for 24 hours before being brought to the medical center.
Which nursing diagnosis has the highest priority?
A. Impaired physical mobility
B. Impaired swallowing
C. Self-care deficit
D. Impaired social interaction
B. Impaired swallowing
– According to Maslow’s Hierarchy of Needs, physiological needs should be addressed first. Therefore, Nancy’s dysphagia is the highest priority nursing diagnosis since she is at risk for aspiration.
Because Nancy is right-handed and is having difficulty performing activities of daily living with the left arm, the nurse also includes the nursing diagnosis “self-care deficit” in the care plan. Which intervention would the nurse implement to address this nursing diagnosis?
A. Use narrow grip utensils to accommodate a weak grasp
B. Recommend a regular type toilet seat with grab hand bars
C. Utilize plate guards when Nancy is eating
D. Discourage Nancy from using assistive devices
C. Utilize plate guards when Nancy is eating
– Plate guards prevent food from being pushed off the plate. Using plate guards and other assistive devices will encourage independence in a client with a self-care deficit.
Which condition is considered a non-modifiable risk factor for a brain attack?
A. High cholesterol levels
B. Obesity
C. History of atrial fibrillation
D. Advanced age
D. Advanced age
– People over age 55 are a high-risk group for a brain attack because the incidence of stroke more than doubles in each successive decade of life. Non-modifiable risk factor means the client cannot do anything to change the risk factor.
Gail tells the nurse she is going to go outside to smoke a cigarette and will only be gone for a few minutes. Which statement is warranted in this situation?
A. “Make sure you smoke in the smoking area only. The hospital has strict rules.”
B. “I should let you know that smoking is a strong risk factor for a brain attack.”
C. “That is just fine. I will be here taking care of your mother.”
D. “How long have you been smoking?”
B. “I should let you know that smoking is a strong risk factor for a brain attack.”
– The nurse should teach Gail that smoking is a modifiable risk factor that could prevent her from having a stroke. Smoking increases the risk for hypertension, which is a risk factor for a stroke.
Nancy is experiencing homonymous hemianopsia as a result of her brain attack. Which nursing intervention would the nurse implement address this condition?
A. Request that the dietary department thicken all liquids on Nancy’s meal and snack trays.
B. Turn Nancy every 2 hours and perform active range of motion exercises.
C. Speak slowly and clearly to assist Nancy in forming sounds to words
D. Place the objects Nancy needs for activities of daily living on the left side of the table.
D. Place the objects Nancy needs for activities of daily living on the left side of the table.
– Homonymous hemianopsia is loss of the visual field on the same side as the paralyzed side. This results in the client neglecting that side of the body, so it is beneficial to place objects on that side. Nancy had a left-hemisphere brain attack so her right side is the weak side.
Nancy is experiencing pain in her right shoulder. The nurse is aware that up to 70% of clients with a brain attack experience severe pain in the shoulder that prevents them from learning new skills. Shoulder function helps clients achieve balance, perform transfer skills, and participate in self-care activities.Which intervention should the nurse implement when addressing this condition?
A. Move Nancy by lifting with the affected shoulder
B. Assist Nancy to keep the affected arm in a dependent position as much as possible
C. Instruct Nancy to clasp the right hand with the left hand and raise both hands above the head
D. Remind Nancy to perform active range of motion exercises daily
C. Instruct Nancy to clasp the right hand with the left hand and raise both hands above the head
– This exercise helps prevent “frozen shoulder” and will aid the nurse when moving or positioning the client.
Gail tells the nurse, “One of the people in the waiting room was telling me about an operation that her mother had to prevent a stroke. Do you know anything about that?”
A. “There is currently no surgery that can help prevent a stroke.”
B. “I am sure your healthcare provider will discuss that with you at a later date.”
C. “That procedure is only done with small strokes, not like the one your Mom had.”
D. “Yes, it is a carotid endarterectomy, and your mother may be able to have one.”
C. “That procedure is only done with small strokes,not like the one your Mom had.”
– This surgery is indicated for clients with symptoms of transient ischemic attack (TIA), or mild stroke, found to be due to severe carotid artery stenosis or moderate stenosis with other significant risk factors.
Which nursing care task should the nurse delegate to the UAP?
A. Assist Nancy to eat her breakfast
B. Use a walker to help Nancy ambulate down the hall
C. Give Nancy a bed bath and change the bed linens
D. Flush Nancy’s saline lock with 2 ml of normal saline
C. Give Nancy a bed bath and change the bed linens
– The UAP can assist Nancy with bathing and then change the bed linens. This task does not require professional judgment or expertise
Which written documentation should the nurse put in the client’s record?
A. PT reported that client became dizzy and was lowered back to the bed with the assistance of a gait belt
B. PT notified the primary nurse that the client could not ambulate at this time because of dizziness
C. Client had difficulty ambulating from the bed to the chair when accompanied by the PT, variance report completed
D. Client experienced orthostatic hypotension when getting out of bed
A. PT reported that client became dizzy and was lowered back to the bed with the assistance of a gait belt
– This documentation provides the factual data of the events that occurred.
Which intervention should the nurse implement to prevent joint deformities?
A. Place the elbow lower than the shoulder and the wrist lower than the elbow on the affected side.
B. Position the fingers so that they are totally flexed in a slight pronation position.
C. Place Nancy in a pone position for 15 minutes at least 4 times a day.
D. Apply splints to the arms and legs during the day but remove at night
C. Place Nancy in a prone position for 15 minutes at least 4 times a day
– This helps to promote hyperextension of the hip joints, which helps prevent knee and hip flexion contractures.
Which rehabilitation team member is responsible for evaluating Nancy’s dysphagia?
A. The occupational therapist
B. The rehabilitation physician
C. The case manager
D. The speech therapist
D. The speech therapist
– The speech therapist evaluates the e client’s gag reflex and ability to swallow, then makes recommendations regarding feeding techniques and diet.