Nokea
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.
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A patient who has a history of a transient ischemic attack (TIA) has an order for Aspirin 160 mg daily. When the nurse is administering the medications, the patient says, 'I don't need the Aspirin today. I don't have any aches or pains.' Which of the following actions should the nurse take?
- A. Document that the Aspirin was refused by the patient.
- B. Tell the patient that the Aspirin is used to prevent aches.
- C. Explain that the Aspirin is ordered to decrease stroke risk.
- D. Call the health care provider to clarify the medication order.
Correct Answer: C
Rationale: Aspirin is ordered to prevent stroke in patients who have experienced TIA. Documentation of the patient's refusal to take the medication is an inadequate response by the nurse. There is no need to clarify the order with the health care provider. The Aspirin is not ordered to prevent aches and pains.
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 receiving a change-of-shift report. Which of the following patients should the nurse see first?
- A. A patient with right-sided weakness who has an infusion of tPA prescribed
- B. A patient who has atrial fibrillation and a new prescription for warfarin
- C. A patient who experienced a transient ischemic attack yesterday who has a dose of Aspirin due
- D. A patient with a subarachnoid hemorrhage 2 days ago who has nimodipine scheduled
Correct Answer: A
Rationale: tPA needs to be infused within the first few hours after stroke symptoms start in order to be effective in minimizing brain injury. The other medications also should be given as quickly as possible, but timing of the medications is not as critical.
The nurse is caring for a patient who has recently experienced a stroke. When reviewing the patients' laboratory report, which of the following results should the nurse report the health care provider?
- A. PaCO2 35 mm Hg
- B. Platelets 95,000/?¼L
- C. Serum sodium 140 mmol/L
- D. Cholesterol 200 mg/dL
Correct Answer: B
Rationale: A low platelet count (95,000/?¼L) increases the risk for bleeding and should be reported to the health care provider, especially in the context of stroke management where anticoagulation or antiplatelet therapy may be considered. Normal PaCO2 (35â??45 mm Hg), serum sodium (135â??145 mmol/L), and cholesterol (less than 200 mg/dL is desirable, but 200 mg/dL is not immediately critical) do not require urgent reporting.
The nurse is admitting a patient who began experiencing right-sided arm and leg weakness to the emergency department. In which order should the nurse implement these actions included in the stroke protocol?
- A. Obtain CT scan without contrast.
- B. Infuse tissue plasminogen activator (tPA).
- C. Administer oxygen to keep O2 saturation >95%.
- D. Use National Institute of Health Stroke Scale to assess patient.
Correct Answer: C,D,A,B
Rationale: The initial actions should be those that help with circulation, airway, and breathing. Baseline neurological assessments should be done next. A CT scan will rule out hemorrhagic stroke before tPA can be administered.