Nokea
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.
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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 receiving a change-of-shift report. Which of the following patients should the nurse see first?
- A. A patient with right-sided weakness who has an infusion of tPA prescribed
- B. A patient who has atrial fibrillation and a new prescription for warfarin
- C. A patient who experienced a transient ischemic attack yesterday who has a dose of Aspirin due
- D. A patient with a subarachnoid hemorrhage 2 days ago who has nimodipine scheduled
Correct Answer: A
Rationale: tPA needs to be infused within the first few hours after stroke symptoms start in order to be effective in minimizing brain injury. The other medications also should be given as quickly as possible, but timing of the medications is not as critical.
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.
The nurse receives a verbal report that a patient has an occlusion of the left posterior cerebral artery. Which of the following findings should the nurse anticipate?
- A. Dysphagia
- B. Confusion
- C. Visual deficits
- D. Poor judgement
Correct Answer: C
Rationale: Visual disturbances are expected with posterior cerebral artery occlusion. Dysphagia occurs with middle cerebral artery involvement. Cognitive deficits and changes in judgement are more typical of anterior cerebral artery occlusion.
Several weeks after a stroke, a patient has urinary incontinence resulting from an impaired awareness of bladder fullness. For an effective bladder training program, which of the following nursing interventions will be best to include in the plan of care?
- A. Limit fluid intake to 1200 mL daily to reduce urine volume.
- B. Assist the patient onto the bedside commode every 2 hours.
- C. Perform intermittent catheterization after each voiding to check for residual urine.
- D. Use an external 'condom' catheter to protect the skin and prevent embarrassment.
Correct Answer: B
Rationale: Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full bladder. A 1200 mL fluid restriction may lead to dehydration. Intermittent catheterization and use of a condom catheter are appropriate in the acute phase of stroke but should not be considered solutions for long-term management because of the risks for urinary tract infection (UTI) and skin breakdown.