Nokea
A patient is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this patient is aware that an absolute contraindication for thrombolytic therapy is what?
- A. Evidence of hemorrhagic stroke
- B. Blood pressure of 180/110 mm Hg
- C. Evidence of stroke evolution
- D. Previous thrombolytic therapy within the past 12 months
Correct Answer: A
Rationale: Thrombolytic therapy is contraindicated in hemorrhagic stroke due to bleeding risk. High BP, stroke evolution, or prior thrombolytic use are not absolute contraindications.
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A nurse in the ICU is providing care for a patient who has been admitted with a hemorrhagic stroke. The nurse is performing frequent neurologic assessments and observes that the patient is becoming progressively more drowsy over the course of the day. What is the nurses best response to this assessment finding?
- A. Report this finding to the physician as an indication of decreased metabolism.
- B. Provide more stimulation to the patient and monitor the patient closely.
- C. Recognize this as the expected clinical course of a hemorrhagic stroke.
- D. Report this to the physician as a possible sign of clinical deterioration.
Correct Answer: D
Rationale: Increasing drowsiness indicates possible deterioration in hemorrhagic stroke, requiring immediate physician notification. It is not expected or due to metabolism, and stimulation is contraindicated.
The nurse is caring for a patient recovering from an ischemic stroke. What intervention best addresses a potential complication after an ischemic stroke?
- A. Providing frequent small meals rather than three larger meals
- B. Teaching the patient to perform deep breathing and coughing exercises
- C. Keeping a urinary catheter in situ for the full duration of recovery
- D. Limiting intake of insoluble fiber
Correct Answer: B
Rationale: Deep breathing and coughing prevent pneumonia, a common stroke complication. Frequent meals, prolonged catheters, and fiber limits are not indicated.
A patient who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurses care of this patient?
- A. The patient should be approached on the side where visual perception is intact.
- B. Attention to the affected side should be minimized to decrease anxiety.
- C. The patient should avoid turning in the direction of the defective visual field to minimize shoulder subluxation.
- D. The patient should be approached on the opposite side of where the visual perception is intact to promote recovery.
Correct Answer: A
Rationale: Approaching on the intact visual side ensures the patient notices the nurse, reducing confusion. Encouraging head turning to the affected side compensates for deficits.
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.