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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.
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The nurse identifies the nursing diagnosis of impaired verbal communication for a patient with expressive aphasia. Which of the following actions should the nurse implement to help the patient communicate?
- A. Have the patient practice facial and tongue exercises.
- B. Ask simple questions that the patient can answer with 'yes' or 'no.'
- C. Develop a list of words that the patient can read and practice reciting.
- D. Prevent embarrassing the patient by changing the subject if the patient does not respond.
Correct Answer: B
Rationale: Communication will be facilitated and less frustrating to the patient when questions that require a 'yes' or 'no' response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to respond.
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 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 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.
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.