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When caring for a patient who has had a stroke, a priority is reduction of ICP. What patient position is most consistent with this goal?
- A. Head turned slightly to the right side
- B. Elevation of the head of the bed
- C. Position changes every 15 minutes while awake
- D. Extension of the neck
Correct Answer: B
Rationale: HOB elevation promotes venous drainage, reducing ICP. Neck extension or frequent position changes may increase ICP, and head turning is less effective.
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The nurse is caring for a patient recovering from an ischemic stroke. What intervention best addresses a potential complication after an ischemic stroke?
- A. Providing frequent small meals rather than three larger meals
- B. Teaching the patient to perform deep breathing and coughing exercises
- C. Keeping a urinary catheter in situ for the full duration of recovery
- D. Limiting intake of insoluble fiber
Correct Answer: B
Rationale: Deep breathing and coughing prevent pneumonia, a common stroke complication. Frequent meals, prolonged catheters, and fiber limits are not indicated.
Stroke after a major ischemic stroke, a possible complication is cerebral edema. Nursing care during the immediate recovery period from an ischemic stroke should include which of the following?
- A. Positioning to avoid hypoxia
- B. Maximizing PaCO2
- C. Administering hypertonic IV solution
- D. Initiating early mobilization
Correct Answer: A
Rationale: Positioning to avoid hypoxia reduces ICP in ischemic stroke recovery. High PaCO2 and early mobilization increase ICP; hypertonic saline is for hyponatremia.
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.
As a member of the stroke team, the nurse knows that thrombolytic therapy carries the potential for benefit and for harm. The nurse should be cognizant of what contraindications for thrombolytic therapy? Select all that apply.
- A. INR above 1.0
- B. Recent intracranial pathology
- C. Sudden symptom onset
- D. Current anticoagulation therapy
- E. Symptom onset greater than 3 hours prior to admission
Correct Answer: B,D,E
Rationale: Recent intracranial pathology, anticoagulation (INR >1.7), and symptom onset >3 hours are thrombolytic contraindications. INR above 1.0 is too low, and sudden onset is not a contraindication.)
During a patients recovery from stroke, the nurse should be aware of predictors of stroke outcome in order to help patients and families set realistic goals. What are the predictors of stroke outcome? Select all that apply.
- A. National Institutes of Health Stroke Scale (NIHSS) score
- B. Race
- C. LOC at time of admission
- D. Gender
- E. Age
Correct Answer: A,C,E
Rationale: NIHSS score, LOC, and age predict stroke outcomes. Race and gender are not significant predictors.