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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.
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The nurse identifies the nursing diagnosis of impaired verbal communication for a patient with expressive aphasia. Which of the following actions should the nurse implement to help the patient communicate?
- A. Have the patient practice facial and tongue exercises.
- B. Ask simple questions that the patient can answer with 'yes' or 'no.'
- C. Develop a list of words that the patient can read and practice reciting.
- D. Prevent embarrassing the patient by changing the subject if the patient does not respond.
Correct Answer: B
Rationale: Communication will be facilitated and less frustrating to the patient when questions that require a 'yes' or 'no' response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to respond.
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.
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 hemiparesis who has arrived by ambulance to the emergency department. Which of the following actions should the nurse take first?
- A. Check the respiratory rate.
- B. Monitor the blood pressure.
- C. Send the patient for a CT scan.
- D. Obtain the Glasgow Coma Scale score.
Correct Answer: A
Rationale: The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway. The other activities should take place quickly after the CABs (circulation, airway, breathing) are completed.
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.