Nokea
The nurse is assessing a patient with a possible stroke and finds that the patient's aphasia started 3.5 hours previously and the blood pressure is 170/92 mm Hg. Which of these prescriptions by the health care provider should the nurse question?
- A. Infuse normal saline at 75 mL/hour.
- B. Keep head of bed elevated at least 30 degrees.
- C. Administer tissue plasminogen activator (tPA) per protocol.
- D. Titrate labetalol drip to keep BP less than 140/90 mm Hg.
Correct Answer: D
Rationale: Because elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if mean arterial pressure (MAP) is >130 mm Hg or systolic pressure is >220 mm Hg. Fluid intake should be 1500-2000 mL daily to maintain cerebral blood flow. The head of the bed should be elevated to at least 30 degrees, unless the patient has symptoms of poor tissue perfusion. tPA may be administered if the patient meets the other criteria for tPA use.
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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 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 with sudden-onset right-sided weakness who has a CT scan and is diagnosed with an intracerebral hemorrhage. Which of the following information about the patient is most important to communicate to the health care provider?
- A. The patient's speech is difficult to understand.
- B. The patient's blood pressure is 144/90 mm Hg.
- C. The patient takes a diuretic because of a history of hypertension.
- D. The patient has atrial fibrillation and takes warfarin.
Correct Answer: D
Rationale: The use of warfarin will have contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patient's care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated.
The nurse is caring for a patient who has had a stroke and has a new prescription to attempt oral feedings. After assessing the patient's gag reflex, which of the following actions should the nurse do next?
- A. Order a varied puréed diet.
- B. Assess the patient's appetite.
- C. Assist the patient into a chair.
- D. Offer the patient a sip of juice.
Correct Answer: C
Rationale: The patient should be as upright as possible before attempting feeding to make swallowing easier and decrease aspiration risk. To assess swallowing ability, the nurse should initially offer water or ice to the patient. Puréed diets are not recommended because the texture is too smooth. The patient may have a poor appetite, but the oral feeding should be attempted regardless.
The nurse is caring for a patient who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects. Which of the following actions should the nurse anticipate as treatment for this patient?
- A. Prophylactic clipping of cerebral aneurysms
- B. Heparin via continuous intravenous infusion
- C. Oral administration of low dose Aspirin therapy
- D. Therapy with tissue plasminogen activator (tPA)
Correct Answer: C
Rationale: The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA.