Nokea
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.
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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.
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 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 is admitted to the hospital with dysphagia and right-sided weakness that resolves in a few hours. The nurse will anticipate teaching the patient about
- A. Alteplase (tPA).
- B. Aspirin.
- C. Warfarin.
- D. Nimodipine.
Correct Answer: B
Rationale: Following a TIA, patients typically are started on medications such as Aspirin to inhibit platelet function and decrease stroke risk. tPA is used for acute ischemic stroke. Warfarin is usually used for patients with atrial fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage.