Nokea
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.
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A patient has been admitted to the ICU after being recently diagnosed with an aneurysm and the patients admission orders include specific aneurysm precautions. What nursing action will the nurse incorporate into the patients plan of care?
- A. Elevate the head of the bed to 45 degrees.
- B. Maintain the patient on complete bed rest.
- C. Administer enemas when the patient is constipated.
- D. Avoid use of thigh-high elastic compression stockings.
Correct Answer: B
Rationale: Complete bed rest reduces BP and bleeding risk in aneurysms. HOB elevation varies, enemas are avoided, and compression stockings are often used.
When caring for a patient who has had a stroke, a priority is reduction of ICP. What patient position is most consistent with this goal?
- A. Head turned slightly to the right side
- B. Elevation of the head of the bed
- C. Position changes every 15 minutes while awake
- D. Extension of the neck
Correct Answer: B
Rationale: HOB elevation promotes venous drainage, reducing ICP. Neck extension or frequent position changes may increase ICP, and head turning is less effective.
A community health nurse is giving an educational presentation about stroke and heart disease at the local senior citizens center. What nonmodifiable risk factor for stroke should the nurse cite?
- A. Female gender
- B. Asian American race
- C. Advanced age
- D. Smoking
Correct Answer: C
Rationale: Advanced age is a nonmodifiable stroke risk factor, with incidence doubling per decade after 55. Male gender, not female, and African American race are risks; smoking is modifiable.
A patient with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the patients cardiac and neurologic status, the nurse monitors the patient for signs of what complication?
- A. Acute pain
- B. Septicemia
- C. Bleeding
- D. Seizures
Correct Answer: C
Rationale: Bleeding is the primary complication of t-PA due to its thrombolytic action. Pain, septicemia, and seizures are less likely.
A patient diagnosed with a hemorrhagic stroke has been admitted to the neurologic ICU. The nurse knows that teaching for the patient and family needs to begin as soon as the patient is settled on the unit and will continue until the patient is discharged. What will family education need to include?
- A. How to differentiate between hemorrhagic and ischemic stroke
- B. Risk factors for ischemic stroke
- C. How to correctly modify the home environment
- D. Techniques for adjusting the patients medication dosages at home
Correct Answer: C
Rationale: Home environment modifications support the patient's disability needs post-stroke. Stroke differentiation and medication adjustments are not family responsibilities.