Nokea
The nurse is caring for a patient who had a stroke resulting from a ruptured aneurysm and subarachnoid hemorrhage. Which of the following interventions should be included in the care plan?
- A. Applying compression gradient stockings
- B. Assisting to dangle on edge of bed and assess for dizziness
- C. Encouraging patient to cough and deep breathe every 4 hours
- D. Inserting an oropharyngeal airway to prevent airway obstruction
Correct Answer: A
Rationale: The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thromboembolism (VTE). Activities such as coughing and sitting up that might increase intracranial pressure (ICP) or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate.
You may also like to solve these questions
The nurse obtains all of the following information about a patient in the clinic. When developing a plan to decrease stroke risk, which of the following risk factors is most important for the nurse to address?
- A. The patient has a daily glass of wine to relax.
- B. The patient is 13 kg above the ideal weight.
- C. The patient works at a desk and relaxes by watching television.
- D. The patient's blood pressure is usually about 180/90 mm Hg.
Correct Answer: D
Rationale: Hypertension is the single most important modifiable risk factor and this patient's hypertension is at the stage 2 level. People who drink more than 1 (for women) or 2 (for men) alcoholic beverages a day may increase risk for hypertension. Physical inactivity and obesity contribute to stroke risk but not so much as hypertension.
The nurse is caring for a patient who has had a stroke and has a new prescription to attempt oral feedings. After assessing the patient's gag reflex, which of the following actions should the nurse do next?
- A. Order a varied puréed diet.
- B. Assess the patient's appetite.
- C. Assist the patient into a chair.
- D. Offer the patient a sip of juice.
Correct Answer: C
Rationale: The patient should be as upright as possible before attempting feeding to make swallowing easier and decrease aspiration risk. To assess swallowing ability, the nurse should initially offer water or ice to the patient. Puréed diets are not recommended because the texture is too smooth. The patient may have a poor appetite, but the oral feeding should be attempted regardless.
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.
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 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.