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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.
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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 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.
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.
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 admitting a patient with left-sided hemiparesis who has arrived by ambulance to the emergency department. Which of the following actions should the nurse take first?
- A. Check the respiratory rate.
- B. Monitor the blood pressure.
- C. Send the patient for a CT scan.
- D. Obtain the Glasgow Coma Scale score.
Correct Answer: A
Rationale: The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway. The other activities should take place quickly after the CABs (circulation, airway, breathing) are completed.