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A nurse is caring for a patient diagnosed with a hemorrhagic stroke. When creating this patients plan of care, what goal should be prioritized?
- A. Prevent complications of immobility.
- B. Maintain and improve cerebral tissue perfusion.
- C. Relieve anxiety and pain.
- D. Relieve sensory deprivation.
Correct Answer: B
Rationale: Cerebral perfusion is a priority physiologic need for survival in hemorrhagic stroke. Other goals are important but secondary.
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A preceptor is discussing stroke with a new nurse on the unit. The preceptor would tell the new nurse which cardiac dysrhythmia is associated with cardiogenic embolic strokes?
- A. Ventricular tachycardia
- B. Atrial fibrillation
- C. Supraventricular tachycardia
- D. Bundle branch block
Correct Answer: B
Rationale: Atrial fibrillation is strongly linked to cardiogenic embolic strokes due to thrombus formation. Other dysrhythmias are less associated.
The nurse is reviewing the medication administration record of a female patient who possesses numerous risk factors for stroke. Which of the woman's medications carries the greatest potential for reducing her risk of stroke?
- A. Naproxen 250 PO b.i.d.
- B. Calcium carbonate 1,000 mg PO b.i.d.
- C. Aspirin 81 mg PO o.d.
- D. Lorazepam 1 mg SL b.i.d. PRN
- G. C
Correct Answer: D
Rationale: Low-dose aspirin reduces stroke risk in high-risk women. Naproxen, calcium, and lorazepam do not have this effect.
What should be included in the patients care plan when establishing an exercise program for a patient affected by a stroke?
- A. Schedule passive range of motion every other day.
- B. Keep activity limited, as the patient may be over stimulated.
- C. Have the patient perform active range-of-motion (ROM) exercises once a day.
- D. Exercise the affected extremities passively four or five times a day.
Correct Answer: D
Rationale: Passive ROM four to five times daily prevents contractures and maintains mobility. Active ROM should be more frequent, and limited activity is not ideal.
A patient has had an ischemic stroke and has been admitted to the medical unit. What action should the nurse perform to best prevent joint deformities?
- A. Place the patient in the prone position for 30 minutes/day.
- B. Assist the patient in acutely flexing the thigh to promote movement.
- C. Place a pillow in the axilla when there is limited external rotation.
- D. Place patients hand in pronation.
Correct Answer: C
Rationale: A pillow in the axilla prevents shoulder adduction, reducing deformity risk. Prone positioning aids hip extension, not daily for 30 minutes. Acute thigh flexion may cause edema, and hand pronation is less functional than supination.
A patient diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse?
- A. Sit with the patient for a few minutes.
- B. Administer an analgesic.
- C. Inform the nurse-manager.
- D. Call the physician immediately.
Correct Answer: D
Rationale: A severe headache may indicate aneurysm leakage, requiring immediate physician notification. Analgesics or sitting with the patient delays critical intervention.