Nokea
The nurse is caring for a patient who had a stroke and is in the acute phase of care. Which of the following systems is priority?
- A. Neurological system
- B. Respiratory system
- C. Gastro-intestinal system
- D. Genito-urinary system
Correct Answer: B
Rationale: During the acute phase following a stroke, management of the respiratory system is a nursing priority. Stroke patients are particularly vulnerable to respiratory problems as it has been shown that respiratory muscle strength decreases following stroke. Advancing age and immobility increase the risk for atelectasis and pneumonia.
You may also like to solve these questions
The nurse is caring for a patient who has had a subarachnoid hemorrhage and is being cared for in the intensive care unit. Which of the following information about vasospasms should the nurse be aware of when planning care?
- A. The patient's blood pressure is 100/50 mm Hg.
- B. Endothelin will subside the vasospasm.
- C. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).
- D. Peak time for occurrence is 7-10 days post bleed.
Correct Answer: D
Rationale: Peak time for vasospasm to occur is 6-20 days after the initial bleed. In addition, release of endothelin (a potent vasoconstrictor) may play a major role in the induction of cerebral vasospasm after SAH rather than helping to relieve it. The BP is within normal limits. RBCs in the CSF are a typical clinical manifestation of a subarachnoid hemorrhage.
The nurse is caring for a patient who has right-sided weakness after a stroke and is attempting to use the left hand for feeding and other activities. The patient's partner insists on feeding and dressing him, telling the nurse, 'I just don't like to see him struggle.' Which of the following nursing diagnoses is most appropriate for the patient?
- A. Situational low self-esteem related to pattern of helplessness
- B. Interrupted family processes related to shift in family roles (effects of illness of a family member)
- C. Disabled family coping related to differing coping styles between support person and patient
- D. Impaired nutrition: less than body requirements related to insufficient dietary intake (hemiplegia and aphasia)
Correct Answer: C
Rationale: The information supports the diagnosis of disabled family coping because the patient's partner does not understand the rehabilitation program. There are no data supporting low self-esteem, and the patient is attempting independence. The data do not support an interruption in family processes because this may be a typical pattern for the couple. There is no indication that the patient has impaired nutrition.
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.
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.
The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to insufficient dietary intake (secondary to impaired self-feeding ability) for a patient with right-sided hemiplegia. Which of the following interventions should be included in the plan of care?
- A. Provide a wide variety of food choices.
- B. Provide oral care before and after meals.
- C. Assist the patient to eat with the left hand.
- D. Teach the patient the 'chin-tuck' technique.
Correct Answer: C
Rationale: Because the nursing diagnosis indicates that the patient's imbalanced nutrition is related to the right-sided hemiplegia, the appropriate interventions will focus on teaching the patient to use the left hand for self-feeding. The other interventions are appropriate for patients with other etiologies for the imbalanced nutrition.