Nokea
The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to insufficient dietary intake (secondary to impaired self-feeding ability) for a patient with right-sided hemiplegia. Which of the following interventions should be included in the plan of care?
- A. Provide a wide variety of food choices.
- B. Provide oral care before and after meals.
- C. Assist the patient to eat with the left hand.
- D. Teach the patient the 'chin-tuck' technique.
Correct Answer: C
Rationale: Because the nursing diagnosis indicates that the patient's imbalanced nutrition is related to the right-sided hemiplegia, the appropriate interventions will focus on teaching the patient to use the left hand for self-feeding. The other interventions are appropriate for patients with other etiologies for the imbalanced nutrition.
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The nurse is caring for a patient who has had a subarachnoid hemorrhage and is being cared for in the intensive care unit. Which of the following information about vasospasms should the nurse be aware of when planning care?
- A. The patient's blood pressure is 100/50 mm Hg.
- B. Endothelin will subside the vasospasm.
- C. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).
- D. Peak time for occurrence is 7-10 days post bleed.
Correct Answer: D
Rationale: Peak time for vasospasm to occur is 6-20 days after the initial bleed. In addition, release of endothelin (a potent vasoconstrictor) may play a major role in the induction of cerebral vasospasm after SAH rather than helping to relieve it. The BP is within normal limits. RBCs in the CSF are a typical clinical manifestation of a subarachnoid hemorrhage.
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 caring for a patient with a stroke who has progressive development of neurological deficits with increasing weakness and decreased level of consciousness (LOC). Which of the following nursing diagnoses has the highest priority for the patient?
- A. Impaired physical mobility related to decrease in muscle strength
- B. Risk for injury as evidenced by alteration in cognitive function
- C. Risk for impaired skin integrity as evidenced by pressure over bony prominence (immobility)
- D. Risk for aspiration as evidenced by impaired ability to swallow
Correct Answer: D
Rationale: Protection of the airway is the priority nursing care for a patient experiencing an acute stroke. The other diagnoses also are appropriate, but interventions to prevent aspiration are the priority at this time.
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 admitting a patient to the emergency department (ED) with right-sided weakness that began 90 minutes ago. Which of the following tests should be prioritized?
- A. Electrocardiogram (ECG)
- B. Complete blood count (CBC)
- C. Chest radiograph (chest x-ray)
- D. Noncontrast computed tomography (CT) scan
Correct Answer: D
Rationale: Rapid screening with a non-contrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 4.5 hours from the onset of clinical manifestations of the stroke. The sooner the tPA is given, the smaller the area of brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.