Chapter 49 Flashcards
Caused by a clot
Thrombotic
Inability to speak or understand language
Aphasia
Difficulty swallowing
Dysphagia
Vision lost in half of visual field
Hemianopsia
Without muscle tone
Flaccid
Imbalanced, staggering pain
Ataxia
Double vision
Diplopia
Paralyzed on one side of the body
Hemiplegia
Healthy tissue surrounding an infarct
Penumbra
Deficient blood flow to organ or tissue
Ischemic
What is the term or acronym for a temporary impairment of cerebral circulation that causes symptoms lasting minutes to hours but results in no permanent neurologic changes?
a) TIA
b) CVA
c) SAH
d) Stroke
a) TIA
A post-myocardial infarction (MI) patient experiencing atrial fibrillation is most at risk for which type of stroke?
a) Hemorrhagic stroke
b) Embolic stroke
c) Thrombotic stroke
d) Cerebral aneurysm
b) Embolic stroke
A nurse approaches a hospitalized post-stroke patient from the patient’s left side to provide morning care. The patient is staring straight ahead and does not respond to the nurse’s presence or voice. Which action should the nurse take first?
a) Walk to the other side of the bed and try again
b) Speak more loudly and clearly
c) Wave his or her fingers in front of the patient’s face
d) Use a picture board to explain to the patient what the nurse is going to do
a) Walk to the other side of the bed and try again
A 72-year-old man is admitted to a skilled care facility following a stroke. When the nursing assistant is bathing him, he makes a sexual remark and tries to touch her inappropriately. The assistant finishes the bath, then tells the LPN in charge, “I refuse to take care of that dirty old man!” Which response by the nurse is the best?
a) “The next time he tries to touch you inappropriately, lightly smack his hand and tell him NO!”
b) “His stroke has made him less inhibited. We’ll see if we can find a male assistant to help him.”
c) “We have to take care of all patients equally, even the dirty old men.”
d) “He didn’t mean anything by it; just ignore it.”
b) “His stroke has made him less inhibited. We’ll see if we can find a male assistant to help him.”
A patient is having difficulty swallowing following a stroke, and a swallowing evaluation is ordered. Which nursing interventions might be recommended to help prevent aspiration during eating? Select all that apply
a) Place the patient in a semi-Fowler’s position
b) Encourage the use of a straw for liquids
c) Provide clear liquids only until the patient can swallow solid foods
d) Have the patient swallow twice after each bite
e) Place food on the unaffected side of the patient’s mouth
f) Check the patient’s mouth for pocketing of food
d, e, f
A patient is unable to control his bowels following a subarachnoid hemorrhage. Which intervention by the nurse can help reduce episodes of bowel incontinence?
a) Ask the patient frequently if he has to have a bowel movement
b) Place incontinence pads on the patient’s bed and chair
c) Toilet the patient according to his preillness schedule, whether or not he feels the urge
d) Take care not to embarrass the patient when incontinent episodes occur
c) Toilet the patient according to his preillness schedule, whether or not he feels the urge
A patient is hospitalized following a stroke. Three days after admission, the patient is able to converse clearly with the nurse in the morning. Early in the afternoon, the patient’s daughter runs out of the room and says, “My mother can’t talk. Somebody help!” Which response by the nurse is the best?
a) Explain to the daughter that this is not uncommon, especially in the afternoon when the patient is tired from morning care activities
b) Do a quick assessment to confirm the change in the patient’s status, then notify the RN or physician STAT
c) Call the speech therapist to come and do a comprehensive speech assessment
d) Show the daughter how to help her mother do the speech exercises that were provided by the therapist
b) Do a quick assessment to confirm the change in the patient’s status, then notify the RN or physician STAT
The nurse is caring for a patient recently admitted with a cerebrovascular accident. The patient is experiencing nausea and begins to vomit. Which of the following actions should the nurse take first?
a) Call for an aide to get suction set up
b) Assist the patient to turn to his side
c) Give an aniemetic as ordered
d) Perform a test for blood on the emesis
b) Assist the patient to turn to his side
The nurse is providing care for a patient with a hemorrhagic stroke. Which of the following medications would the nurse question? Select all that apply
a) Simvastatin (Zocor)
b) Clopidogrel (Plavix)
c) Carbamazepine (Tegretol)
d) Tissue plasminogen activator (tPA)
e) Metoprolol (Toprol)
f) Warfarin (Coumadin)
b, d, f
A 67-year-old gentleman being evaluated and treated for a cerebrovascular accident has Clopidogrel (Plavix) ordered, PO now. Which of the following would cause the nurse to hold the medication? Select all that apply
a) The patient has weak grip strength in the right hand and strong in the left
b) The patient’s smile is crooked
c) The patient’s gag reflex is positive
d) The patient’s voice sounds gurgly after taking a sip of water
e) The patient’s blood pressure is 168/90 mm Hg
f) The patient has an allergy to aspirin
b, d
What are the most common cerebrovascular disorders?
TIA, ischemic stroke and hemorrhagic stroke
Temporary blockage of blood to the brain that causes a transient (brief) neurologic impairment
TIA
Disruption of blood flow to the brain resulting in death of brain cells
CVA (stroke)
There is an area of the brain tissue surrounding the damage, called the ______, which contains brain cells that are “stunned” and may be revived if the brain is reperfused quickly
penumbra
What determines the area of the brain affected and the symptoms that result?
The particular vessel or vessels involved
What are the 2 classifications of a stroke
ischemic or hemorrhagic
