Nokea
The nurse is caring for a patient with a stroke who has progressive development of neurological deficits with increasing weakness and decreased level of consciousness (LOC). Which of the following nursing diagnoses has the highest priority for the patient?
- A. Impaired physical mobility related to decrease in muscle strength
- B. Risk for injury as evidenced by alteration in cognitive function
- C. Risk for impaired skin integrity as evidenced by pressure over bony prominence (immobility)
- D. Risk for aspiration as evidenced by impaired ability to swallow
Correct Answer: D
Rationale: Protection of the airway is the priority nursing care for a patient experiencing an acute stroke. The other diagnoses also are appropriate, but interventions to prevent aspiration are the priority at this time.
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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 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.
The health care provider recommends a carotid endarterectomy for a patient with carotid atherosclerosis and a history of transient ischemic attacks (TIA). The patient asks the nurse to describe the procedure. Which of the following responses by the nurse is appropriate?
- A. The carotid endarterectomy involves surgical removal of plaque from an artery in the neck.
- B. The diseased portion of the artery in the brain is removed and replaced with a synthetic graft.
- C. A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed.
- D. A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque.
Correct Answer: A
Rationale: In a carotid endarterectomy, the carotid artery is incised and the plaque is removed. The response beginning, 'The diseased portion of the artery in the brain is removed' describes an arterial graft procedure. The answer beginning, 'A catheter with a deflated balloon is positioned at the narrow area' describes an angioplasty. The final response beginning, 'A wire is threaded through the artery' describes the MERCI procedure.
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 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.