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The nurse is caring for a patient who had a stroke affecting the right hemisphere of the brain. Which of the following nursing diagnoses is appropriate based on knowledge of the effects of right brain damage?
- A. Impaired physical mobility related to decrease in muscle control (right hemiplegia)
- B. Risk for injury as evidenced by alteration in cognitive functioning
- C. Impaired verbal communication related to environmental barrier (impaired speech)
- D. Ineffective coping related to insufficient sense of control (depression and distress about disability)
Correct Answer: B
Rationale: Right-sided brain damage typically causes denial of any deficits and poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability.
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The nurse is caring for a patient with a left-sided brain stroke who suddenly bursts into tears when family members visit. Which of the following actions should the nurse implement?
- A. Use a calm voice to ask the patient to stop the crying behaviour.
- B. Explain to the family that depression is normal following a stroke.
- C. Have the family members leave the patient alone for a few minutes.
- D. Teach the family that emotional outbursts are common after strokes.
Correct Answer: D
Rationale: Patients who have left-sided brain stroke are prone to emotional outbursts, which are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient's outburst suggests that depression is not the major cause of the behaviour. The family should stay with the patient. The crying is not within the patient's control and asking the patient to stop will lead to embarrassment.
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 health care provider prescribes clopidogrel for a patient with cerebral atherosclerosis. Which of the following information should the nurse include when teaching the patient about the new medication?
- A. Monitor and record the blood pressure daily.
- B. Call the health care provider if stools are tarry.
- C. It will dissolve clots in the cerebral arteries.
- D. It will reduce cerebral artery plaque formation.
Correct Answer: B
Rationale: Clopidogrel (Plavix) inhibits platelet function as it increases the risk for bleeding, so patients should be advised to notify the health care provider about any signs of bleeding. The medication does not lower blood pressure, decrease plaque formation, or dissolve clots.
The nurse is caring for a patient with a stroke who has progressive development of neurological deficits with increasing weakness and decreased level of consciousness (LOC). Which of the following nursing diagnoses has the highest priority for the patient?
- A. Impaired physical mobility related to decrease in muscle strength
- B. Risk for injury as evidenced by alteration in cognitive function
- C. Risk for impaired skin integrity as evidenced by pressure over bony prominence (immobility)
- D. Risk for aspiration as evidenced by impaired ability to swallow
Correct Answer: D
Rationale: Protection of the airway is the priority nursing care for a patient experiencing an acute stroke. The other diagnoses also are appropriate, but interventions to prevent aspiration are the priority at this time.
The nurse is admitting a patient to the emergency department (ED) with right-sided weakness that began 90 minutes ago. Which of the following tests should be prioritized?
- A. Electrocardiogram (ECG)
- B. Complete blood count (CBC)
- C. Chest radiograph (chest x-ray)
- D. Noncontrast computed tomography (CT) scan
Correct Answer: D
Rationale: Rapid screening with a non-contrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 4.5 hours from the onset of clinical manifestations of the stroke. The sooner the tPA is given, the smaller the area of brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.