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Several weeks after a stroke, a patient has urinary incontinence resulting from an impaired awareness of bladder fullness. For an effective bladder training program, which of the following nursing interventions will be best to include in the plan of care?
- A. Limit fluid intake to 1200 mL daily to reduce urine volume.
- B. Assist the patient onto the bedside commode every 2 hours.
- C. Perform intermittent catheterization after each voiding to check for residual urine.
- D. Use an external 'condom' catheter to protect the skin and prevent embarrassment.
Correct Answer: B
Rationale: Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full bladder. A 1200 mL fluid restriction may lead to dehydration. Intermittent catheterization and use of a condom catheter are appropriate in the acute phase of stroke but should not be considered solutions for long-term management because of the risks for urinary tract infection (UTI) and skin breakdown.
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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.
A patient who has a history of a transient ischemic attack (TIA) has an order for Aspirin 160 mg daily. When the nurse is administering the medications, the patient says, 'I don't need the Aspirin today. I don't have any aches or pains.' Which of the following actions should the nurse take?
- A. Document that the Aspirin was refused by the patient.
- B. Tell the patient that the Aspirin is used to prevent aches.
- C. Explain that the Aspirin is ordered to decrease stroke risk.
- D. Call the health care provider to clarify the medication order.
Correct Answer: C
Rationale: Aspirin is ordered to prevent stroke in patients who have experienced TIA. Documentation of the patient's refusal to take the medication is an inadequate response by the nurse. There is no need to clarify the order with the health care provider. The Aspirin is not ordered to prevent aches and pains.
The nurse is caring for a patient with a left-sided brain stroke who suddenly bursts into tears when family members visit. Which of the following actions should the nurse implement?
- A. Use a calm voice to ask the patient to stop the crying behaviour.
- B. Explain to the family that depression is normal following a stroke.
- C. Have the family members leave the patient alone for a few minutes.
- D. Teach the family that emotional outbursts are common after strokes.
Correct Answer: D
Rationale: Patients who have left-sided brain stroke are prone to emotional outbursts, which are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient's outburst suggests that depression is not the major cause of the behaviour. The family should stay with the patient. The crying is not within the patient's control and asking the patient to stop will lead to embarrassment.
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.
The nurse is caring for a patient who has right-sided weakness after a stroke and is attempting to use the left hand for feeding and other activities. The patient's partner insists on feeding and dressing him, telling the nurse, 'I just don't like to see him struggle.' Which of the following nursing diagnoses is most appropriate for the patient?
- A. Situational low self-esteem related to pattern of helplessness
- B. Interrupted family processes related to shift in family roles (effects of illness of a family member)
- C. Disabled family coping related to differing coping styles between support person and patient
- D. Impaired nutrition: less than body requirements related to insufficient dietary intake (hemiplegia and aphasia)
Correct Answer: C
Rationale: The information supports the diagnosis of disabled family coping because the patient's partner does not understand the rehabilitation program. There are no data supporting low self-esteem, and the patient is attempting independence. The data do not support an interruption in family processes because this may be a typical pattern for the couple. There is no indication that the patient has impaired nutrition.