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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.
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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.
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.
A patient with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this patient?
- A. Range-of-motion exercises to prevent contractures
- B. Encouraging independence with ADLs to promote recovery
- C. Early initiation of physical therapy
- D. Absolute bed rest in a quiet, nonstimulating environment
Correct Answer: D
Rationale: Absolute bed rest minimizes BP elevation, reducing bleeding risk in cerebral aneurysms. Activity-based interventions increase ICP and are contraindicated.
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 patient has been admitted to the ICU after being recently diagnosed with an aneurysm and the patients admission orders include specific aneurysm precautions. What nursing action will the nurse incorporate into the patients plan of care?
- A. Elevate the head of the bed to 45 degrees.
- B. Maintain the patient on complete bed rest.
- C. Administer enemas when the patient is constipated.
- D. Avoid use of thigh-high elastic compression stockings.
Correct Answer: B
Rationale: Complete bed rest reduces BP and bleeding risk in aneurysms. HOB elevation varies, enemas are avoided, and compression stockings are often used.