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A patient who has a history of a transient ischemic attack (TIA) has an order for Aspirin 160 mg daily. When the nurse is administering the medications, the patient says, 'I don't need the Aspirin today. I don't have any aches or pains.' Which of the following actions should the nurse take?
- A. Document that the Aspirin was refused by the patient.
- B. Tell the patient that the Aspirin is used to prevent aches.
- C. Explain that the Aspirin is ordered to decrease stroke risk.
- D. Call the health care provider to clarify the medication order.
Correct Answer: C
Rationale: Aspirin is ordered to prevent stroke in patients who have experienced TIA. Documentation of the patient's refusal to take the medication is an inadequate response by the nurse. There is no need to clarify the order with the health care provider. The Aspirin is not ordered to prevent aches and pains.
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The nurse is caring for a patient who has had a stroke and has a new prescription to attempt oral feedings. After assessing the patient's gag reflex, which of the following actions should the nurse do next?
- A. Order a varied puréed diet.
- B. Assess the patient's appetite.
- C. Assist the patient into a chair.
- D. Offer the patient a sip of juice.
Correct Answer: C
Rationale: The patient should be as upright as possible before attempting feeding to make swallowing easier and decrease aspiration risk. To assess swallowing ability, the nurse should initially offer water or ice to the patient. Puréed diets are not recommended because the texture is too smooth. The patient may have a poor appetite, but the oral feeding should be attempted regardless.
The nurse identifies the nursing diagnosis of impaired verbal communication for a patient with expressive aphasia. Which of the following actions should the nurse implement to help the patient communicate?
- A. Have the patient practice facial and tongue exercises.
- B. Ask simple questions that the patient can answer with 'yes' or 'no.'
- C. Develop a list of words that the patient can read and practice reciting.
- D. Prevent embarrassing the patient by changing the subject if the patient does not respond.
Correct Answer: B
Rationale: Communication will be facilitated and less frustrating to the patient when questions that require a 'yes' or 'no' response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to respond.
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.
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.
Several weeks after a stroke, a patient has urinary incontinence resulting from an impaired awareness of bladder fullness. For an effective bladder training program, which of the following nursing interventions will be best to include in the plan of care?
- A. Limit fluid intake to 1200 mL daily to reduce urine volume.
- B. Assist the patient onto the bedside commode every 2 hours.
- C. Perform intermittent catheterization after each voiding to check for residual urine.
- D. Use an external 'condom' catheter to protect the skin and prevent embarrassment.
Correct Answer: B
Rationale: Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full bladder. A 1200 mL fluid restriction may lead to dehydration. Intermittent catheterization and use of a condom catheter are appropriate in the acute phase of stroke but should not be considered solutions for long-term management because of the risks for urinary tract infection (UTI) and skin breakdown.