Nokea
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.
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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 has recently experienced a stroke. When reviewing the patients' laboratory report, which of the following results should the nurse report the health care provider?
- A. PaCO2 35 mm Hg
- B. Platelets 95,000/?¼L
- C. Serum sodium 140 mmol/L
- D. Cholesterol 200 mg/dL
Correct Answer: B
Rationale: A low platelet count (95,000/?¼L) increases the risk for bleeding and should be reported to the health care provider, especially in the context of stroke management where anticoagulation or antiplatelet therapy may be considered. Normal PaCO2 (35â??45 mm Hg), serum sodium (135â??145 mmol/L), and cholesterol (less than 200 mg/dL is desirable, but 200 mg/dL is not immediately critical) do not require urgent reporting.
A patient who has a history of a transient ischemic attack (TIA) has an order for Aspirin 160 mg daily. When the nurse is administering the medications, the patient says, 'I don't need the Aspirin today. I don't have any aches or pains.' Which of the following actions should the nurse take?
- A. Document that the Aspirin was refused by the patient.
- B. Tell the patient that the Aspirin is used to prevent aches.
- C. Explain that the Aspirin is ordered to decrease stroke risk.
- D. Call the health care provider to clarify the medication order.
Correct Answer: C
Rationale: Aspirin is ordered to prevent stroke in patients who have experienced TIA. Documentation of the patient's refusal to take the medication is an inadequate response by the nurse. There is no need to clarify the order with the health care provider. The Aspirin is not ordered to prevent aches and pains.
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 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.