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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.
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The nurse obtains all of the following information about a patient in the clinic. When developing a plan to decrease stroke risk, which of the following risk factors is most important for the nurse to address?
- A. The patient has a daily glass of wine to relax.
- B. The patient is 13 kg above the ideal weight.
- C. The patient works at a desk and relaxes by watching television.
- D. The patient's blood pressure is usually about 180/90 mm Hg.
Correct Answer: D
Rationale: Hypertension is the single most important modifiable risk factor and this patient's hypertension is at the stage 2 level. People who drink more than 1 (for women) or 2 (for men) alcoholic beverages a day may increase risk for hypertension. Physical inactivity and obesity contribute to stroke risk but not so much as hypertension.
The nurse is caring for a patient who had a stroke and is in the acute phase of care. Which of the following systems is priority?
- A. Neurological system
- B. Respiratory system
- C. Gastro-intestinal system
- D. Genito-urinary system
Correct Answer: B
Rationale: During the acute phase following a stroke, management of the respiratory system is a nursing priority. Stroke patients are particularly vulnerable to respiratory problems as it has been shown that respiratory muscle strength decreases following stroke. Advancing age and immobility increase the risk for atelectasis and pneumonia.
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 is caring for a patient who has recently experienced a stroke. When reviewing the patients' laboratory report, which of the following results should the nurse report the health care provider?
- A. PaCO2 35 mm Hg
- B. Platelets 95,000/?¼L
- C. Serum sodium 140 mmol/L
- D. Cholesterol 200 mg/dL
Correct Answer: B
Rationale: A low platelet count (95,000/?¼L) increases the risk for bleeding and should be reported to the health care provider, especially in the context of stroke management where anticoagulation or antiplatelet therapy may be considered. Normal PaCO2 (35â??45 mm Hg), serum sodium (135â??145 mmol/L), and cholesterol (less than 200 mg/dL is desirable, but 200 mg/dL is not immediately critical) do not require urgent reporting.
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.