Nokea
The nurse is caring for a patient diagnosed with an ischemic stroke and knows that effective positioning of the patient is important. Which of the following should be integrated into the patients plan of care?
- A. The patients hip joint should be maintained in a flexed position.
- B. The patient should be in a supine position unless ambulating.
- C. The patient should be placed in a prone position for 15 to 30 minutes several times a day.
- D. The patient should be placed in a Trendelenberg position two to three times daily to promote cerebral perfusion.
Correct Answer: C
Rationale: Prone positioning with pelvic support promotes hip extension, preventing contractures. Flexed hips, supine-only positioning, and Trendelenberg are inappropriate.
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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.
When preparing to discharge a patient home, the nurse has met with the family and warned them that the patient may exhibit unexpected emotional responses. The nurse should teach the family that these responses are typically a result of what cause?
- A. Frustration around changes in function and communication
- B. Unmet physiologic needs
- C. Changes in brain activity during sleep and wakefulness
- D. Temporary changes in metabolism
Correct Answer: A
Rationale: Emotional responses post-stroke often stem from frustration with functional and communication deficits. Other causes should be ruled out.
A patient who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurses care of this patient?
- A. The patient should be approached on the side where visual perception is intact.
- B. Attention to the affected side should be minimized to decrease anxiety.
- C. The patient should avoid turning in the direction of the defective visual field to minimize shoulder subluxation.
- D. The patient should be approached on the opposite side of where the visual perception is intact to promote recovery.
Correct Answer: A
Rationale: Approaching on the intact visual side ensures the patient notices the nurse, reducing confusion. Encouraging head turning to the affected side compensates for deficits.
A nursing student is writing a care plan for a newly admitted patient who has been diagnosed with a stroke. What major nursing diagnosis should most likely be included in the patients plan of care?
- A. Adult failure to thrive
- B. Post-trauma syndrome
- C. Hyperthermia
- D. Disturbed sensory perception
Correct Answer: D
Rationale: Disturbed sensory perception is a common stroke-related diagnosis due to sensory deficits. Other options are less directly associated.
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.