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A client has been found unresponsive at home for an undetermined period of time. A cerebrovascular accident (CVA)Ib> suspected, and the family is demanding a clot buster be used to restore functioning. The nurse knows that successful use of tissue plasminogen activator (TPA) in a client with CVA requires which factor(s) to be true? Select all that apply.
- A. Symptoms no longer evolving
- B. Presence of an ischemic stroke
- C. Used concurrently with heparin therapy
- D. Administered intramuscularly for faster response
- E. Administered within 3 hours of onset of symptoms
- F. Administered for hemorrhagic strokes
Correct Answer: B,E
Rationale: TPA is a thrombolytic agent that can limit neurologic deficits if given IV within 3 hours of onset of an ischemic CVA. Waiting for symptoms to stabilize (no longer evolving) may take days and would not be appropriate for the use of TPA. TPA is not used in conjunction with other anticoagulants and would never be used to treat a hemorrhagic stroke (promotes more bleeding).
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A client who has experienced an initial transient ischemic attack (TIA) states: 'I'm glad it wasn't anything serious.' Which is the best nursing response to this statement?
- A. I sense that you are happy it was not a stroke.
- B. People who experience a TIA will develop a stroke.
- C. TIA symptoms are short-lived and resolve within 24 hours.
- D. TIA is a warning sign. Let's talk about lowering your risks.
Correct Answer: D
Rationale: TIA is a warning sign and can be used to empower clients to make life changes to lower the risks. Sensing the client is happy is a psychotherapeutic response but does not lead to teaching and learning for health promotion. TIAs can lead to a stroke for approximately one third of the clients but is not a definitive result and presents as a frightening statement without empowering change. TIA symptoms are short-lived, but this is a factual statement that does not provide additional information to the client.
Which nursing assessment finding is most indicative of a hemorrhagic stroke?
- A. Client history of atrial fibrillation
- B. Sudden onset of breathing alterations
- C. Symptoms evolving over 24 to 48 hours
- D. Client history of hyperlipidemia
Correct Answer: B
Rationale: Hemorrhagic strokes are less common than ischemic strokes and usually present with sudden onset and have the most impact on breathing, blood pressure, and heart rate. Client history of atrial fibrillation and hyperlipidemia are most significant with ischemic strokes caused by embolus or plaque. Ischemic strokes tend to evolve over 24 to 48 hours until symptoms complete.
A client has tension headaches. The nurse recommends massage as a treatment for tension headaches. How does massage help clients with tension headaches?
- A. Reduces hypotension
- B. Increases appetite
- C. Relaxes muscles
- D. Relieves migraines
Correct Answer: C
Rationale: Massaging relaxes tense muscles, causes local dilation of blood vessels, and relieves headache. However, this approach is not likely to help a client with migraine or cluster headaches. Massage is not offered to clients with tension headaches to increase their appetite or reduce hypotension.
A client is prescribed sumatriptan for the treatment of migraine headache. Which client statement would indicate a need for additional teaching from the nurse?
- A. I use this to prevent migraines.
- B. I take this when I get a headache.
- C. It constricts the blood vessels in my head.
- D. It alleviates my sensitivity to light and sound.
Correct Answer: A
Rationale: Sumatriptan is a serotonin receptor agonist that stimulates serotonin receptors in the brain and causes vasoconstriction of the cerebral arteries and reduce/eliminate headaches and other symptoms associated with migraines. Sumatriptan is used during an attack and is not indicated for preventative migraine therapy.
A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which finding?
- A. Transient ischemic attack (TIA)
- B. Left-sided cerebrovascular accident (CVA)
- C. Right-sided cerebrovascular accident (CVA)
- D. Completed Stroke
Correct Answer: B
Rationale: When the infarct is on the left side of the brain, the symptoms are likely to be on the right, and the speech is more likely to be involved. If the MRI reveals an infarct, TIA is no longer the diagnosis. There is not enough information to determine if the stroke is still evolving or is complete.