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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.
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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 female patient is diagnosed with a right-sided stroke. The patient is now experiencing hemianopsia. How might the nurse help the patient manage her potential sensory and perceptional difficulties?
- A. Keep the lighting in the patients room low.
- B. Place the patients clock on the affected side.
- C. Approach the patient on the side where vision is impaired.
- D. Place the patients extremities where she can see them.
Correct Answer: D
Rationale: Placing extremities in the intact visual field reduces neglect in hemianopsia. Approaching on the intact side and keeping lighting adequate also help.
The nurse is performing stroke risk screenings at a hospital open house. The nurse has identified four patients who might be at risk for a stroke. Which patient is likely at the highest risk for a hemorrhagic stroke?
- A. White female, age 60, with history of excessive alcohol intake
- B. White male, age 60, with history of uncontrolled hypertension
- C. Black male, age 60, with history of diabetes
- D. Black male, age 50, with history of smoking
Correct Answer: B
Rationale: Uncontrolled hypertension is the primary risk factor for hemorrhagic stroke. Alcohol, diabetes, and smoking increase risk but are less significant than hypertension.
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.
The nurse is discharging home a patient who suffered a stroke. He has a flaccid right arm and leg and is experiencing problems with urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common patient response to a change in body image?
- A. Denial
- B. Fear
- C. Depression
- D. Disassociation
Correct Answer: C
Rationale: Stroke often leads to depression due to loss of function and independence. Denial, fear, or disassociation may occur but are less common responses to body image changes.