Nokea
The charge nurse is teaching a nursing student about immediate stroke care. Which of the following information should the nurse share with the nursing student?
- A. Hypotension post stroke is normal.
- B. Antihypertensive medication is administered if the mean arterial pressure is >130 mm Hg.
- C. Diuretic ordered if the systolic BP is >160 mm Hg.
- D. Withholding medications until the degree of dysphagia is known.
Correct Answer: B
Rationale: Elevated BP is common immediately after a stroke and may be a protective response to maintain cerebral perfusion. Immediately following ischemic stroke, use of drugs to lower BP is recommended only if BP is markedly increased (mean arterial pressure >130 mm Hg or systolic BP >220 mm Hg). Withholding medications can be dangerous; medications do not have to be given by the oral route.
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The nurse is admitting a patient who began experiencing right-sided arm and leg weakness to the emergency department. In which order should the nurse implement these actions included in the stroke protocol?
- A. Obtain CT scan without contrast.
- B. Infuse tissue plasminogen activator (tPA).
- C. Administer oxygen to keep O2 saturation >95%.
- D. Use National Institute of Health Stroke Scale to assess patient.
Correct Answer: C,D,A,B
Rationale: The initial actions should be those that help with circulation, airway, and breathing. Baseline neurological assessments should be done next. A CT scan will rule out hemorrhagic stroke before tPA can be administered.
The nurse receives a verbal report that a patient has an occlusion of the left posterior cerebral artery. Which of the following findings should the nurse anticipate?
- A. Dysphagia
- B. Confusion
- C. Visual deficits
- D. Poor judgement
Correct Answer: C
Rationale: Visual disturbances are expected with posterior cerebral artery occlusion. Dysphagia occurs with middle cerebral artery involvement. Cognitive deficits and changes in judgement are more typical of anterior cerebral artery occlusion.
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.
The nurse is caring for a patient who had a stroke affecting the right hemisphere of the brain. Which of the following nursing diagnoses is appropriate based on knowledge of the effects of right brain damage?
- A. Impaired physical mobility related to decrease in muscle control (right hemiplegia)
- B. Risk for injury as evidenced by alteration in cognitive functioning
- C. Impaired verbal communication related to environmental barrier (impaired speech)
- D. Ineffective coping related to insufficient sense of control (depression and distress about disability)
Correct Answer: B
Rationale: Right-sided brain damage typically causes denial of any deficits and poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability.
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.