Nokea
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.
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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 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.
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.
A patient with a history of several transient ischemic attacks (TIAs) arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. Which of the following procedures should the nurse anticipate?
- A. Surgical endarterectomy
- B. Transluminal angioplasty
- C. Intravenous heparin administration
- D. Tissue plasminogen activator (tPA) infusion
Correct Answer: D
Rationale: The patient's history and clinical manifestations suggest an acute ischemic stroke and a patient who is seen within 3-4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is having an acute ischemic stroke.
The nurse is admitting a patient with left-sided homonymous hemianopsia resulting from a stroke. Which of the following interventions should the nurse include in the plan of care during the acute period of the stroke?
- A. Apply an eye patch to the left eye.
- B. Approach the patient from the left side.
- C. Place objects needed for activities of daily living on the patient's right side.
- D. Reassure the patient that the visual deficit will resolve as the stroke progresses.
Correct Answer: C
Rationale: During the acute period, the nurse should place objects on the patient's unaffected side. Since there is a visual defect in the left half of each eye, an eye patch is not appropriate. The patient should be approached from the right side. The visual deficit may not resolve, although the patient can learn to compensate for the defect.