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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.
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The nurse is caring for a patient with a stroke who has progressive development of neurological deficits with increasing weakness and decreased level of consciousness (LOC). Which of the following nursing diagnoses has the highest priority for the patient?
- A. Impaired physical mobility related to decrease in muscle strength
- B. Risk for injury as evidenced by alteration in cognitive function
- C. Risk for impaired skin integrity as evidenced by pressure over bony prominence (immobility)
- D. Risk for aspiration as evidenced by impaired ability to swallow
Correct Answer: D
Rationale: Protection of the airway is the priority nursing care for a patient experiencing an acute stroke. The other diagnoses also are appropriate, but interventions to prevent aspiration are the priority at this time.
The health care provider prescribes clopidogrel for a patient with cerebral atherosclerosis. Which of the following information should the nurse include when teaching the patient about the new medication?
- A. Monitor and record the blood pressure daily.
- B. Call the health care provider if stools are tarry.
- C. It will dissolve clots in the cerebral arteries.
- D. It will reduce cerebral artery plaque formation.
Correct Answer: B
Rationale: Clopidogrel (Plavix) inhibits platelet function as it increases the risk for bleeding, so patients should be advised to notify the health care provider about any signs of bleeding. The medication does not lower blood pressure, decrease plaque formation, or dissolve clots.
The nurse obtains all of the following information about a patient in the clinic. When developing a plan to decrease stroke risk, which of the following risk factors is most important for the nurse to address?
- A. The patient has a daily glass of wine to relax.
- B. The patient is 13 kg above the ideal weight.
- C. The patient works at a desk and relaxes by watching television.
- D. The patient's blood pressure is usually about 180/90 mm Hg.
Correct Answer: D
Rationale: Hypertension is the single most important modifiable risk factor and this patient's hypertension is at the stage 2 level. People who drink more than 1 (for women) or 2 (for men) alcoholic beverages a day may increase risk for hypertension. Physical inactivity and obesity contribute to stroke risk but not so much as hypertension.
The nurse is admitting a patient to the emergency department (ED) with right-sided weakness that began 90 minutes ago. Which of the following tests should be prioritized?
- A. Electrocardiogram (ECG)
- B. Complete blood count (CBC)
- C. Chest radiograph (chest x-ray)
- D. Noncontrast computed tomography (CT) scan
Correct Answer: D
Rationale: Rapid screening with a non-contrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 4.5 hours from the onset of clinical manifestations of the stroke. The sooner the tPA is given, the smaller the area of brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.
The nurse is admitting a patient with left-sided homonymous hemianopsia resulting from a stroke. Which of the following interventions should the nurse include in the plan of care during the acute period of the stroke?
- A. Apply an eye patch to the left eye.
- B. Approach the patient from the left side.
- C. Place objects needed for activities of daily living on the patient's right side.
- D. Reassure the patient that the visual deficit will resolve as the stroke progresses.
Correct Answer: C
Rationale: During the acute period, the nurse should place objects on the patient's unaffected side. Since there is a visual defect in the left half of each eye, an eye patch is not appropriate. The patient should be approached from the right side. The visual deficit may not resolve, although the patient can learn to compensate for the defect.