Aneurysm, AVM, Intracranial bleed Flashcards
A 68-year-old patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin?
a. The patient has dysphasia.
b. The patient has atrial fibrillation.
c. The patient reports that symptoms began with a severe headache.
d. The patient has a history of brief episodes of right-sided hemiplegia.
ANS: C
A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack (TIA) are not contraindications to aspirin use, so the nurse can administer the aspirin.
A 73-year-old patient with a stroke experiences facial drooping on the right side and right-sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find?
a. Impulsive behavior
b. Right-sided neglect
c. Hyperactive left-sided tendon reflexes
d. Difficulty comprehending instructions
ANS: D
Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with comprehension and use of language. The left-side reflexes are likely to be intact. Impulsive behavior and neglect are more likely with a right-side stroke.
A patient admitted with possible stroke has been aphasic for 3 hours and his current blood pressure (BP) is 174/94 mm Hg. Which order by the health care provider should the nurse question?
a. Keep head of bed elevated at least 30 degrees.
b. Infuse normal saline intravenously at 75 mL/hr.
c. Administer tissue plasminogen activator (tPA) per protocol.
d. Administer a labetalol (Normodyne) drip to keep BP less than 140/90 mm Hg.
ANS: D
Because elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if mean arterial pressure (MAP) is >130 mm Hg or systolic pressure is >220 mm Hg. Fluid intake should be 1500 to 2000 mL daily to maintain cerebral blood flow. The head of the bed should be elevated to at least 30 degrees, unless the patient has symptoms of poor tissue perfusion. tPA may be administered if the patient meets the other criteria for tPA use.
A 56-year-old patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously, and health records show a history of several transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for
a. surgical endarterectomy.
b. transluminal angioplasty.
c. intravenous heparin administration.
d. tissue plasminogen activator (tPA) infusion.
ANS: D
The patients history and clinical manifestations suggest an acute ischemic stroke and a patient who is seen within 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.
A patient is admitted to the hospital with a left hemiplegia. To determine the size and location and to ascertain whether a stroke is ischemic or hemorrhagic, the nurse anticipates that the health care provider will request a
a. CT scan
b. lumbar puncture
c. cerebral arteriogram
d. positron emission tomography (PET)
A: CT scan- A CT scan is the most commonly used diagnostic test to determine the size and location of the lesion and to differentiate a thrombotic stroke from a hemorrhagic stroke. Positron emission tomography (PET) will show the metabolic activity of the brain and provide a depiction of the extent of tissue damage after a stroke. Lumbar punctures are not performed routinely because of the chance of increased intracranial pressure causing herniation. Cerebral arteriograms are invasive and may dislodge an embolism or cause further hemorrhage; they are performed only when no other test can provide the needed information.
The priority intervention in the emergency department for the patient with a stroke is
a. intravenous fluid replacement
b. administration of osmotic diuretics to reduce cerebral edema
c. initiation of hypothermia to decrease the oxygen needs of the brain
d. maintenance of respiratory function with a patent airway and oxygen administration
D: Maintenance of respiratory function with a patent airway and oxygen administration- the first priority in acute management of the patient with a stroke is preservation of life. Because the patient with a stroke may be unconscious or have a reduced gag reflex, it is most important to maintain a patent airway for the patient and provide oxygen if respiratory effort is impaired. IV fluid replacement, treatment with osmotic diuretics, and perhaps hypothermia may be used for further treatment.
A diagnosis of a ruptured cerebral aneurysm has been made in a patient with manifestations of a stroke. The nurse anticipates that treatment options that would be evaluated for the patient include
a. hyperventilation therapy
b. surgical clipping of the aneurysm
c. administration of hyperosmotic agents
d. administration of thrombolytic therapy
B: Surgical clipping of they aneurysm- Surgical management with clipping of an aneurysm to decrease re bleeding and vasospasm is an option for a stroke cause by rupture of a cerebral aneurysm. Placement of coils into the lumens of the aneurysm by intercentional radiologists is increasing in popularity. Hyperventilation therapy would increase vasodilation and the potential for hemorrhage. Thrombolytic therapy would be absolutely contraindicated, and if a vessel is patent, osmotic diuretics may leak into tissue, pulling fluid out of the vessel and increasing edema.
For a patient who had a right hemisphere stroke the nurse establishes a nursing diagnosis of
a.
risk for injury related to denial of deficits and impulsiveness.
b.
impaired physical mobility related to right-sided hemiplegia.
c.
impaired verbal communication related to speech-language deficits.
d.
ineffective coping related to depression and distress about disability.
ANS: A
The patient with right-sided brain damage typically denies any deficits and has poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability.
During the acute phase of a stroke, the nurse assesses the patient’s vital signs and neurologic status every 4 hours. A cardiovascular sign that the nurse would see as the body attempts to increase cerebral blood flow is
a. hypertension
b. fluid overload
c. cardiac dysrhythmias
d. S3 and S4 heart sounds
A: Hypertension- The body responds to the vasopasm and a decreased circulation to the brain that occurs with a stroke by increasing the BP, frequently resulting in hypertension. The other options are important cardiovascular factors to assess, but they do not result from impaired cerebral blood flow.
A nursing intervention is indicated for the patient with hemiplegia is
a. the use of a footboard to prevent plantar flexion
b. immobilization of the affected arm against the chest with a sling
c. positioning the patient in bed with each joint lower than the joint proximal to it
d. having the patient perform passive ROM of the affected limb with the unaffected limb
D: Having the patient perform passive ROM of the affected limb with the unaffected limb- active ROM should be initiated on the unaffected side as soon as possible, and passive ROM of the affected side should be started on the first day. Having the patient actively exercise the unaffected side provides the patient with active and passive ROM as needed. Use of footboards is controversial because they stimulate plantar flexion. The unaffected arm should be supported, but immobilization may precipitate a painful shoulder-hand syndrome. The patient should be positioned with each joint higher than the joint proximal to it to prevent dependent edema.
A 40-year-old patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan?
a.
Apply intermittent pneumatic compression stockings.
b.
Assist to dangle on edge of bed and assess for dizziness.
c.
Encourage patient to cough and deep breathe every 4 hours.
d.
Insert an oropharyngeal airway to prevent airway obstruction.
ANS: A
The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thromboembolism (VTE). Activities such as coughing and sitting up that might increase intracranial pressure (ICP) or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate.
A patient with a stroke has a right sided hemiplegia. The nurse prepares family members to help control behavior changes seen with this type of stroke by teaching them to
a. ignore undesirable behaviors manifested by the patient
b. provide directions to the patient verbally in small steps
c. distract the patient from inappropriate emotional responses
d. supervise all activities before allowing the patient to pursue them independently
C: Distract the patient from inappropriate emotional responses- patients with left-sided brain damage from stroke often experience emotional lability, inappropriate emotional responses, mood swings, and uncontrolled tears or laughter disproportionate or out of context with the situation. The behavior is upsetting and embarrassing to both the patient and the family, and the patient should be distracted to minimize its presence. Patients with right-brain damage often have impulsive, rapid behavior that supervision and direction.
Which stroke risk factor for a 48-year-old male patient in the clinic is most important for the nurse to address?
a.
The patient is 25 pounds above the ideal weight.
b.
The patient drinks a glass of red wine with dinner daily.
c.
The patients usual blood pressure (BP) is 170/94 mm Hg.
d.
The patient works at a desk and relaxes by watching television.
ANS: C
Hypertension is the single most important modifiable risk factor. People who drink more than 1 (for women) or 2 (for men) alcoholic beverages a day may increase risk for hypertension. Physical inactivity and obesity contribute to stroke risk but not as much as hypertension.
A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider?
a.
The patients speech is difficult to understand.
b.
The patients 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 (Coumadin).
ANS: D
The use of warfarin probably 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 patients 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.
A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first?
a.
Complete blood count (CBC)
b.
Chest radiograph (Chest x-ray)
c.
12-Lead electrocardiogram (ECG)
d.
Noncontrast computed tomography (CT) scan
ANS: D
Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 4.5 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the less brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.
