Nokea
A patient is admitted to the hospital with dysphagia and right-sided weakness that resolves in a few hours. The nurse will anticipate teaching the patient about
- A. Alteplase (tPA).
- B. Aspirin.
- C. Warfarin.
- D. Nimodipine.
Correct Answer: B
Rationale: Following a TIA, patients typically are started on medications such as Aspirin to inhibit platelet function and decrease stroke risk. tPA is used for acute ischemic stroke. Warfarin is usually used for patients with atrial fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage.
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The nurse is caring for a patient who had a stroke and is in the acute phase of care. Which of the following systems is priority?
- A. Neurological system
- B. Respiratory system
- C. Gastro-intestinal system
- D. Genito-urinary system
Correct Answer: B
Rationale: During the acute phase following a stroke, management of the respiratory system is a nursing priority. Stroke patients are particularly vulnerable to respiratory problems as it has been shown that respiratory muscle strength decreases following stroke. Advancing age and immobility increase the risk for atelectasis and pneumonia.
The nurse is assessing a patient with a possible stroke and finds that the patient's aphasia started 3.5 hours previously and the blood pressure is 170/92 mm Hg. Which of these prescriptions by the health care provider should the nurse question?
- A. Infuse normal saline at 75 mL/hour.
- B. Keep head of bed elevated at least 30 degrees.
- C. Administer tissue plasminogen activator (tPA) per protocol.
- D. Titrate labetalol drip to keep BP less than 140/90 mm Hg.
Correct Answer: D
Rationale: Because elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if mean arterial pressure (MAP) is >130 mm Hg or systolic pressure is >220 mm Hg. Fluid intake should be 1500-2000 mL daily to maintain cerebral blood flow. The head of the bed should be elevated to at least 30 degrees, unless the patient has symptoms of poor tissue perfusion. tPA may be administered if the patient meets the other criteria for tPA use.
A patient with a history of several transient ischemic attacks (TIAs) arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. Which of the following procedures should the nurse anticipate?
- A. Surgical endarterectomy
- B. Transluminal angioplasty
- C. Intravenous heparin administration
- D. Tissue plasminogen activator (tPA) infusion
Correct Answer: D
Rationale: The patient's history and clinical manifestations suggest an acute ischemic stroke and a patient who is seen within 3-4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is having an acute ischemic stroke.
The nurse is caring for a patient who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects. Which of the following actions should the nurse anticipate as treatment for this patient?
- A. Prophylactic clipping of cerebral aneurysms
- B. Heparin via continuous intravenous infusion
- C. Oral administration of low dose Aspirin therapy
- D. Therapy with tissue plasminogen activator (tPA)
Correct Answer: C
Rationale: The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA.
The nurse is caring for a patient who had a stroke resulting from a ruptured aneurysm and subarachnoid hemorrhage. Which of the following interventions should be included in the care plan?
- A. Applying compression gradient stockings
- B. Assisting to dangle on edge of bed and assess for dizziness
- C. Encouraging patient to cough and deep breathe every 4 hours
- D. Inserting an oropharyngeal airway to prevent airway obstruction
Correct Answer: A
Rationale: The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thromboembolism (VTE). Activities such as coughing and sitting up that might increase intracranial pressure (ICP) or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate.