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The pathophysiology of an ischemic stroke involves the ischemic cascade, which includes the following steps: 1. Change in pH 2. Blood flow decreases 3. A switch to anaerobic respiration 4. Membrane pumps fail 5. Cells cease to function 6. Lactic acid is generated. Put these steps in order in which they occur.
- A. 635241
- B. 352416
- C. 236145
- D. 162534
Correct Answer: C
Rationale: The ischemic cascade starts with decreased blood flow (2), then anaerobic respiration (3), lactic acid generation (6), pH change (1), membrane pump failure (4), and cell dysfunction (5).
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A patient who has experienced an ischemic stroke has been admitted to the medical unit. The patients family in adamant that she remain on bed rest to hasten her recovery and to conserve energy. What principle of care should inform the nurses response to the family?
- A. The patient should mobilize as soon as she is physically able.
- B. To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks.
- C. The patient should remain on bed rest until she expresses a desire to mobilize.
- D. Lack of mobility will greatly increase the patients risk of stroke recurrence.
Correct Answer: A
Rationale: Early mobilization prevents complications like contractures and DVT. Prolonged bed rest or waiting for patient initiative is not recommended.
The nurse is assessing a patient with a suspected stroke. What assessment finding is most suggestive of a stroke?
- A. Facial droop
- B. Dysrhythmias
- C. Periorbital edema
- D. Projectile vomiting
Correct Answer: A
Rationale: Facial droop is a classic stroke sign. Dysrhythmias, edema, and vomiting are less specific or common in acute stroke.
When caring for a patient who had a hemorrhagic stroke, close monitoring of vital signs and neurologic changes is imperative. What is the earliest sign of deterioration in a patient with a hemorrhagic stroke of which the nurse should be aware?
- A. Generalized pain
- B. Alteration in level of consciousness (LOC)
- C. Tonicclonic seizures
- D. Shortness of breath
Correct Answer: B
Rationale: Altered LOC, such as drowsiness or slurred speech, is the earliest sign of deterioration in hemorrhagic stroke. Pain, seizures, and shortness of breath are not typical early signs.
A rehabilitation nurse caring for a patient who has had a stroke is approached by the patients family and asked why the patient has to do so much for herself when she is obviously struggling. What would be the nurses best answer?
- A. We are trying to help her be as useful as possible.
- B. The focus on care in a rehabilitation facility is to help the patient to resume as much self-care as possible.
- C. We aren't here to care for her the way the hospital staff did; we are here to help her get better so she can go home.
- D. Rehabilitation means helping patients do exactly what they did before their stroke.
Correct Answer: B
Rationale: Rehabilitation emphasizes restoring self-care to maximize independence. Other responses oversimplify or misrepresent rehabilitation goals.
A female patient is diagnosed with a right-sided stroke. The patient is now experiencing hemianopsia. How might the nurse help the patient manage her potential sensory and perceptional difficulties?
- A. Keep the lighting in the patients room low.
- B. Place the patients clock on the affected side.
- C. Approach the patient on the side where vision is impaired.
- D. Place the patients extremities where she can see them.
Correct Answer: D
Rationale: Placing extremities in the intact visual field reduces neglect in hemianopsia. Approaching on the intact side and keeping lighting adequate also help.