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A client is brought to the emergency department with symptoms of a cerebrovascular accident (CVA). The nurse would anticipate which diagnostic evaluation to be completed prior to initiation of treatment?
- A. Prothrombin level
- B. Chest x-ray
- C. Brain CT scan or MRI
- D. Lumbar puncture
Correct Answer: C
Rationale: CT scan or MRI differentiates CVA from other disorders and can differentiate between ischemic or hemorrhagic strokes. PT level would be done if the client is receiving anticoagulant therapy. Chest x-ray may be performed if respiratory concerns are indicated. Lumbar puncture would be done if subarachnoid bleeding is suspected.
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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).
A female client who complains of recurring headaches, accompanied by increased irritability, photophobia, and fatigue is asked to track the headache symptoms and occurrence on a calendar log. Which is the best nursing rationale for this action?
- A. Cluster headaches can cause severe debilitating pain.
- B. Migraines often coincide with menstrual cycle.
- C. Tension headaches are easier to treat.
- D. Headaches are the most common type of reported pain.
Correct Answer: B
Rationale: Changes in reproductive hormones as found during the menstrual cycle can be a trigger for migraine headaches and may assist in the management of the symptoms. Cluster headaches can cause severe pain, but this is not the reason for tracking. Tension headaches can be managed, but this is not associated with a monthly calendar. Headaches are common, but that is not the reason for tracking.
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.
The nurse is providing teaching to a client who reports tension headaches. Which instruction would be beneficial to prevent onset of symptoms?
- A. Apply cool or warm cloth to head or eyes.
- B. Eliminate use of bright lights when working.
- C. Avoid certain foods.
- D. Perform stretching exercises and frequent position changes.
Correct Answer: D
Rationale: Tension headaches are often associated with prolonged tensed muscles. Application of cool or warm cloths and avoidance of bright lights may help to reduce the headache after occurrence. Avoiding certain foods may prevent migraine headaches but is not likely to prevent tension headaches.
A client presents to the walk-in clinic complaining of a migraine. The client is prescribed an antileptic. What should the nurse suggest to the client?
- A. Avoid crowds.
- B. Take drugs only after meals at night.
- C. Avoid caffeine and alcohol.
- D. Use caution while driving or performing hazardous activities.
Correct Answer: D
Rationale: A client who is prescribed an antileptic needs to exercise caution while driving and avoid performing hazardous activities. A client taking non-steroidal anti-inflammatory drugs should be advised against taking caffeine and alcohol. The client need not take the drug only at night after meals or be instructed to avoid crowds.