Cerebrovascular Disorders

Question 1

The nurse admits a patient to the ED with new onset of slurred speech and right-sided weakness. What is the priority nursing action?

Answer 1

Determine the time of symptom onset/ airway

Question 2

A client has signs of increased ICP. Which of the following is anearlyindicator of deterioration in the client’s condition?

Answer 2

Decrease in LOC (level of consciousness)

Question 3

Define cerebral aneurism:

Answer 3

A bulge or ballooning of a vessel in the brain

Question 4

List the s/s of a ruptured cerebral aneurism:

Answer 4

1. Sudden onset of a sever headache
2. Nuco-rigidity (stiff neck)
3. Photophobia

Question 5

What are the three components of the cranium?

Answer 5

1. Brain tissue/ tissue
2. CSF
3. Blood

Question 6

What is the normal range of ICP?

Answer 6

5 - 15 mmHG

Question 7

What is the normal range of CCP?

Answer 7

60 - 100 mmHg

Question 8

What is the FIRST thing a patient notices as pressure increases in the early stages of a CVA?

Answer 8

Decrease level of consciousness (LOC)

Question 9

What is the scale used to assess a patients level of consciousness?

Answer 9

Glasgow Coma Scale

Question 10

What is the score range of the GCS (Glasglow Coma Scale)?

Answer 10

3 - 15

Question 11

If a patient is having a CVA and is becoming progressively weaker and their condition is worsening, as a nurse, what will be the first priority?

Answer 11

Airway is the first priority (aspiration)

Question 12

What does the acronym FAST mean, pertaining to stroke?

Answer 12

Face
Arms
Speech
Time

Question 13

What does each letter in the acronym FAST correlate to actually doing?

Answer 13

F- looking for drooping on one side
A- looking for weakness on one side
S- speech will become slurred
T- time is a gauge when the patient was last seen normal. This is when the time starts; when they were last seen normal (aka well time)

Question 14

List the modifiable risk factors to stroke:

Answer 14

1. Smoking
2. Obesity (change your diet)
3. Sedentary life style

Question 15

What effect does an increase in PaCO2 or hypercapnia have on cranial pressure?

Answer 15

Hypercapnia will cause increased cranial pressure

Question 16

A patient comes in with S/S of CVA. They have facial drooping and their speech is slurred. How do you confirm a CVA? What is the diagnostic test that would be ran?

Answer 16

CT scan

Question 17

When would a tPA be contraindicated?

Answer 17

1. It would not be administered if it was a hemorrhagic stroke
2. You would not give med. if its been more than 4.5 hours since the patient was last seen normal

Question 18

Define dysarthria:

Answer 18

Difficulty with speech

Question 19

What does the acronym TIA stand for?

Answer 19

Trans-ischemic-attack

Question 20

What is a tPA?

Answer 20

A powerful clot buster

Question 21

What does TIA mean?

Answer 21

1. A mini stroke or warning stroke
2. TIA symptoms mimic stroke symptoms
3. A precursor for having a major stroke`

Question 22

Define deCORticate:

Answer 22

Arms/ hands are drawn into the core of the body and feet are turned inward.
Damage to the brain at the core

Question 23

Define decerebrate:

Answer 23

[The worst]. Indicates damage to brain stem and arms and legs are straight out.