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The nurse is discharging home a patient who suffered a stroke. He has a flaccid right arm and leg and is experiencing problems with urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common patient response to a change in body image?
- A. Denial
- B. Fear
- C. Depression
- D. Disassociation
Correct Answer: C
Rationale: Stroke often leads to depression due to loss of function and independence. Denial, fear, or disassociation may occur but are less common responses to body image changes.
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The patient has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the patients atmosphere more conducive to communication?
- A. Provide a board of commonly used needs and phrases.
- B. Have the patient speak to loved ones on the phone daily.
- C. Help the patient complete his or her sentences.
- D. Speak in a loud and deliberate voice to the patient.
Correct Answer: A
Rationale: A communication board reduces frustration by providing visual aids for needs. Completing sentences or loud speech may frustrate the patient, and phone calls may not be feasible.
A patient has been admitted to the ICU after being recently diagnosed with an aneurysm and the patients admission orders include specific aneurysm precautions. What nursing action will the nurse incorporate into the patients plan of care?
- A. Elevate the head of the bed to 45 degrees.
- B. Maintain the patient on complete bed rest.
- C. Administer enemas when the patient is constipated.
- D. Avoid use of thigh-high elastic compression stockings.
Correct Answer: B
Rationale: Complete bed rest reduces BP and bleeding risk in aneurysms. HOB elevation varies, enemas are avoided, and compression stockings are often used.
A nurse in the ICU is providing care for a patient who has been admitted with a hemorrhagic stroke. The nurse is performing frequent neurologic assessments and observes that the patient is becoming progressively more drowsy over the course of the day. What is the nurses best response to this assessment finding?
- A. Report this finding to the physician as an indication of decreased metabolism.
- B. Provide more stimulation to the patient and monitor the patient closely.
- C. Recognize this as the expected clinical course of a hemorrhagic stroke.
- D. Report this to the physician as a possible sign of clinical deterioration.
Correct Answer: D
Rationale: Increasing drowsiness indicates possible deterioration in hemorrhagic stroke, requiring immediate physician notification. It is not expected or due to metabolism, and stimulation is contraindicated.
A patient diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse?
- A. Sit with the patient for a few minutes.
- B. Administer an analgesic.
- C. Inform the nurse-manager.
- D. Call the physician immediately.
Correct Answer: D
Rationale: A severe headache may indicate aneurysm leakage, requiring immediate physician notification. Analgesics or sitting with the patient delays critical intervention.
A community health nurse is giving an educational presentation about stroke and heart disease at the local senior citizens center. What nonmodifiable risk factor for stroke should the nurse cite?
- A. Female gender
- B. Asian American race
- C. Advanced age
- D. Smoking
Correct Answer: C
Rationale: Advanced age is a nonmodifiable stroke risk factor, with incidence doubling per decade after 55. Male gender, not female, and African American race are risks; smoking is modifiable.