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The nurse is assessing a patient with a suspected stroke. What assessment finding is most suggestive of a stroke?
- A. Facial droop
- B. Dysrhythmias
- C. Periorbital edema
- D. Projectile vomiting
Correct Answer: A
Rationale: Facial droop is a classic stroke sign. Dysrhythmias, edema, and vomiting are less specific or common in acute stroke.
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The pathophysiology of an ischemic stroke involves the ischemic cascade, which includes the following steps: 1. Change in pH 2. Blood flow decreases 3. A switch to anaerobic respiration 4. Membrane pumps fail 5. Cells cease to function 6. Lactic acid is generated. Put these steps in order in which they occur.
- A. 635241
- B. 352416
- C. 236145
- D. 162534
Correct Answer: C
Rationale: The ischemic cascade starts with decreased blood flow (2), then anaerobic respiration (3), lactic acid generation (6), pH change (1), membrane pump failure (4), and cell dysfunction (5).
A patient diagnosed with a hemorrhagic stroke has been admitted to the neurologic ICU. The nurse knows that teaching for the patient and family needs to begin as soon as the patient is settled on the unit and will continue until the patient is discharged. What will family education need to include?
- A. How to differentiate between hemorrhagic and ischemic stroke
- B. Risk factors for ischemic stroke
- C. How to correctly modify the home environment
- D. Techniques for adjusting the patients medication dosages at home
Correct Answer: C
Rationale: Home environment modifications support the patient's disability needs post-stroke. Stroke differentiation and medication adjustments are not family responsibilities.
A patient with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the patients cardiac and neurologic status, the nurse monitors the patient for signs of what complication?
- A. Acute pain
- B. Septicemia
- C. Bleeding
- D. Seizures
Correct Answer: C
Rationale: Bleeding is the primary complication of t-PA due to its thrombolytic action. Pain, septicemia, and seizures are less likely.
A community health nurse is giving an educational presentation about stroke and heart disease at the local senior citizens center. What nonmodifiable risk factor for stroke should the nurse cite?
- A. Female gender
- B. Asian American race
- C. Advanced age
- D. Smoking
Correct Answer: C
Rationale: Advanced age is a nonmodifiable stroke risk factor, with incidence doubling per decade after 55. Male gender, not female, and African American race are risks; smoking is modifiable.
The nurse is preparing health education for a patient who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in this education?
- A. Mild, intermittent seizures can be expected.
- B. Take ibuprofen for complaints of a serious headache.
- C. Take antihypertensive medication as ordered.
- D. Drowsiness is normal for the first week after discharge.
Correct Answer: C
Rationale: Antihypertensive therapy is critical to manage hypertension, a key risk factor for hemorrhagic stroke. Seizures, ibuprofen use, and drowsiness are not normal or advised.