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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.
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A patient with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this patient?
- A. Range-of-motion exercises to prevent contractures
- B. Encouraging independence with ADLs to promote recovery
- C. Early initiation of physical therapy
- D. Absolute bed rest in a quiet, nonstimulating environment
Correct Answer: D
Rationale: Absolute bed rest minimizes BP elevation, reducing bleeding risk in cerebral aneurysms. Activity-based interventions increase ICP and are contraindicated.
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.)
The nurse is caring for a patient diagnosed with an ischemic stroke and knows that effective positioning of the patient is important. Which of the following should be integrated into the patients plan of care?
- A. The patients hip joint should be maintained in a flexed position.
- B. The patient should be in a supine position unless ambulating.
- C. The patient should be placed in a prone position for 15 to 30 minutes several times a day.
- D. The patient should be placed in a Trendelenberg position two to three times daily to promote cerebral perfusion.
Correct Answer: C
Rationale: Prone positioning with pelvic support promotes hip extension, preventing contractures. Flexed hips, supine-only positioning, and Trendelenberg are inappropriate.
A patient who just suffered a suspected ischemic stroke is brought to the ED by ambulance. On what should the nurses primary assessment focus?
- A. Cardiac and respiratory status
- B. Seizure activity
- C. Pain
- D. Fluid and electrolyte balance
Correct Answer: A
Rationale: Airway, breathing, and circulation (ABCs) are the priority in acute stroke to ensure airway patency and oxygenation. Seizures, pain, and fluid balance are assessed later.
The nurse is assessing a patient with a suspected stroke. What assessment finding is most suggestive of a stroke?
- A. Facial droop
- B. Dysrhythmias
- C. Periorbital edema
- D. Projectile vomiting
Correct Answer: A
Rationale: Facial droop is a classic stroke sign. Dysrhythmias, edema, and vomiting are less specific or common in acute stroke.