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Following diagnostic testing, a patient has been admitted to the ICU and placed on cerebral aneurysm precautions. What nursing action should be included in patients plan of care?
- A. Supervise the patients activities of daily living closely.
- B. Initiate early ambulation to prevent complications of immobility.
- C. Provide a high-calorie, low-protein diet.
- D. Perform all of the patient's hygiene and feeding.
Correct Answer: A
Rationale: Close supervision of ADLs prevents exertion that could elevate BP in aneurysm precautions. Ambulation and dietary restrictions are not indicated, and some ADLs may be allowed.
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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.
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 nursing student is writing a care plan for a newly admitted patient who has been diagnosed with a stroke. What major nursing diagnosis should most likely be included in the patients plan of care?
- A. Adult failure to thrive
- B. Post-trauma syndrome
- C. Hyperthermia
- D. Disturbed sensory perception
Correct Answer: D
Rationale: Disturbed sensory perception is a common stroke-related diagnosis due to sensory deficits. Other options are less directly associated.
During a patients recovery from stroke, the nurse should be aware of predictors of stroke outcome in order to help patients and families set realistic goals. What are the predictors of stroke outcome? Select all that apply.
- A. National Institutes of Health Stroke Scale (NIHSS) score
- B. Race
- C. LOC at time of admission
- D. Gender
- E. Age
Correct Answer: A,C,E
Rationale: NIHSS score, LOC, and age predict stroke outcomes. Race and gender are not significant predictors.
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.