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A female patient is diagnosed with a right-sided stroke. The patient is now experiencing hemianopsia. How might the nurse help the patient manage her potential sensory and perceptional difficulties?
- A. Keep the lighting in the patients room low.
- B. Place the patients clock on the affected side.
- C. Approach the patient on the side where vision is impaired.
- D. Place the patients extremities where she can see them.
Correct Answer: D
Rationale: Placing extremities in the intact visual field reduces neglect in hemianopsia. Approaching on the intact side and keeping lighting adequate also help.
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As a member of the stroke team, the nurse knows that thrombolytic therapy carries the potential for benefit and for harm. The nurse should be cognizant of what contraindications for thrombolytic therapy? Select all that apply.
- A. INR above 1.0
- B. Recent intracranial pathology
- C. Sudden symptom onset
- D. Current anticoagulation therapy
- E. Symptom onset greater than 3 hours prior to admission
Correct Answer: B,D,E
Rationale: Recent intracranial pathology, anticoagulation (INR >1.7), and symptom onset >3 hours are thrombolytic contraindications. INR above 1.0 is too low, and sudden onset is not a contraindication.)
A rehabilitation nurse caring for a patient who has had a stroke is approached by the patients family and asked why the patient has to do so much for herself when she is obviously struggling. What would be the nurses best answer?
- A. We are trying to help her be as useful as possible.
- B. The focus on care in a rehabilitation facility is to help the patient to resume as much self-care as possible.
- C. We aren't here to care for her the way the hospital staff did; we are here to help her get better so she can go home.
- D. Rehabilitation means helping patients do exactly what they did before their stroke.
Correct Answer: B
Rationale: Rehabilitation emphasizes restoring self-care to maximize independence. Other responses oversimplify or misrepresent rehabilitation goals.
A patient has recently begun mobilizing during the recovery from an ischemic stroke. To protect the patients safety during mobilization, the nurse should perform what action?
- A. Support the patients full body weight with a waist belt during ambulation.
- B. Have a colleague follow the patient closely with a wheelchair.
- C. Avoid mobilizing the patient in the early morning or late evening.
- D. Ensure that the patients family members do not participate in mobilization.
Correct Answer: B
Rationale: A wheelchair nearby ensures safety if the patient becomes fatigued or dizzy. Family participation is encouraged, and timing is not restricted.
When preparing to discharge a patient home, the nurse has met with the family and warned them that the patient may exhibit unexpected emotional responses. The nurse should teach the family that these responses are typically a result of what cause?
- A. Frustration around changes in function and communication
- B. Unmet physiologic needs
- C. Changes in brain activity during sleep and wakefulness
- D. Temporary changes in metabolism
Correct Answer: A
Rationale: Emotional responses post-stroke often stem from frustration with functional and communication deficits. Other causes should be ruled out.
After a subarachnoid hemorrhage, the patients laboratory results indicate a serum sodium level of less than 126 mEq/L. What is the nurses most appropriate action?
- A. Administer a bolus of normal saline as ordered.
- B. Prepare the patient for thrombolytic therapy as ordered.
- C. Facilitate testing for hypothalamic dysfunction.
- D. Prepare to administer 3% NaCl by IV as ordered.
Correct Answer: D
Rationale: Hyponatremia post-subarachnoid hemorrhage suggests SIADH or cerebral salt-wasting, treated with hypertonic 3% saline. Normal saline may worsen the issue, and other options are irrelevant.