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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.
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A patient with a history of several transient ischemic attacks (TIAs) arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. Which of the following procedures should the nurse anticipate?
- A. Surgical endarterectomy
- B. Transluminal angioplasty
- C. Intravenous heparin administration
- D. Tissue plasminogen activator (tPA) infusion
Correct Answer: D
Rationale: The patient's history and clinical manifestations suggest an acute ischemic stroke and a patient who is seen within 3-4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is having an acute ischemic stroke.
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 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.
The health care provider recommends a carotid endarterectomy for a patient with carotid atherosclerosis and a history of transient ischemic attacks (TIA). The patient asks the nurse to describe the procedure. Which of the following responses by the nurse is appropriate?
- A. The carotid endarterectomy involves surgical removal of plaque from an artery in the neck.
- B. The diseased portion of the artery in the brain is removed and replaced with a synthetic graft.
- C. A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed.
- D. A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque.
Correct Answer: A
Rationale: In a carotid endarterectomy, the carotid artery is incised and the plaque is removed. The response beginning, 'The diseased portion of the artery in the brain is removed' describes an arterial graft procedure. The answer beginning, 'A catheter with a deflated balloon is positioned at the narrow area' describes an angioplasty. The final response beginning, 'A wire is threaded through the artery' describes the MERCI procedure.
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.