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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.
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A patient who has experienced an ischemic stroke has been admitted to the medical unit. The patients family in adamant that she remain on bed rest to hasten her recovery and to conserve energy. What principle of care should inform the nurses response to the family?
- A. The patient should mobilize as soon as she is physically able.
- B. To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks.
- C. The patient should remain on bed rest until she expresses a desire to mobilize.
- D. Lack of mobility will greatly increase the patients risk of stroke recurrence.
Correct Answer: A
Rationale: Early mobilization prevents complications like contractures and DVT. Prolonged bed rest or waiting for patient initiative is not recommended.
A patient recovering from a stroke has severe shoulder pain from subluxation of the shoulder and is being cared for on the unit. To prevent further injury and pain, the nurse caring for this patient is aware of what principle of care?
- A. The patient should be fitted with a cast because use of a sling should be avoided due to adduction of the affected shoulder.
- B. Elevation of the arm and hand can lead to further complications associated with edema.
- C. Passively exercising the affected extremity is avoided to minimize pain.
- D. The patient should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder.
Correct Answer: D
Rationale: Interlacing fingers and moving scapulae forward safely exercises the shoulder, reducing subluxation pain. Slings are used, elevation prevents edema, and passive exercise is beneficial.
A patient diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for what purpose?
- A. To decrease cerebral edema
- B. To prevent seizure activity that is common following a TIA
- C. To remove atherosclerotic plaques blocking cerebral flow
- D. To determine the cause of the TIA
Correct Answer: C
Rationale: Carotid endarterectomy removes plaques to prevent stroke in patients with occlusive carotid disease. It does not address edema, seizures, or TIA causation.
The nurse is reviewing the medication administration record of a female patient who possesses numerous risk factors for stroke. Which of the woman's medications carries the greatest potential for reducing her risk of stroke?
- A. Naproxen 250 PO b.i.d.
- B. Calcium carbonate 1,000 mg PO b.i.d.
- C. Aspirin 81 mg PO o.d.
- D. Lorazepam 1 mg SL b.i.d. PRN
- G. C
Correct Answer: D
Rationale: Low-dose aspirin reduces stroke risk in high-risk women. Naproxen, calcium, and lorazepam do not have this effect.
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.