Nokea
The nurse is caring for a patient recovering from an ischemic stroke. What intervention best addresses a potential complication after an ischemic stroke?
- A. Providing frequent small meals rather than three larger meals
- B. Teaching the patient to perform deep breathing and coughing exercises
- C. Keeping a urinary catheter in situ for the full duration of recovery
- D. Limiting intake of insoluble fiber
Correct Answer: B
Rationale: Deep breathing and coughing prevent pneumonia, a common stroke complication. Frequent meals, prolonged catheters, and fiber limits are not indicated.
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The nurse is performing stroke risk screenings at a hospital open house. The nurse has identified four patients who might be at risk for a stroke. Which patient is likely at the highest risk for a hemorrhagic stroke?
- A. White female, age 60, with history of excessive alcohol intake
- B. White male, age 60, with history of uncontrolled hypertension
- C. Black male, age 60, with history of diabetes
- D. Black male, age 50, with history of smoking
Correct Answer: B
Rationale: Uncontrolled hypertension is the primary risk factor for hemorrhagic stroke. Alcohol, diabetes, and smoking increase risk but are less significant than hypertension.
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 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.
The public health nurse is planning a health promotion campaign that reflects current epidemiologic trends. The nurse should know that hemorrhagic stroke currently accounts for what percentage of total strokes in the United States?
- A. 43%
- B. 33%
- C. 23%
- D. 13%
Correct Answer: D
Rationale: Hemorrhagic strokes account for 13% of total strokes, with ischemic strokes comprising 87%.
A patient who has experienced an ischemic stroke has been admitted to the medical unit. The patients family in adamant that she remain on bed rest to hasten her recovery and to conserve energy. What principle of care should inform the nurses response to the family?
- A. The patient should mobilize as soon as she is physically able.
- B. To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks.
- C. The patient should remain on bed rest until she expresses a desire to mobilize.
- D. Lack of mobility will greatly increase the patients risk of stroke recurrence.
Correct Answer: A
Rationale: Early mobilization prevents complications like contractures and DVT. Prolonged bed rest or waiting for patient initiative is not recommended.