Med Surg - Exam 3 - Ch 58 (Nursing Management: Stroke) COPY

Question 1

What is the priority intervention in the emergency department for the patient with a stroke?

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 patent airway and oxygen administration

Answer 1

d. Maintenance of respiratory function with patent airway and oxygen administration

The first priority in acute management of the patient with a stroke is the preservation of life. Because the patient of 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 avoiding hyperthermia may be used for further treatment.

Question 2

During the acute phase of a stroke, the nurse assesses the patient’s vital signs and neurologic status every 4 hours. What is a cardiovascular sign that the nurse would see as a body attempts to increase cerebral blood flow?

a. Hypertension
b. Fluid overload
c. Cardiac dysrhythmias
d. S3 and S4 heart sounds

Answer 2

a. Hypertension

The body responds to the vasospasm and 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.

Question 3

What is a nursing intervention that is indicated for the patient with hemiplegia?

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 range of motion (ROM) of the affected limb with the unaffected limb

Answer 3

d. Having the patient perform passive range of motion (ROM) of the affected limb with the unaffected limb

Active range of motion (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.

Question 4

A newly admitted patient diagnosed with right-sided brain stroke has a nursing diagnosis of disturbed visual sensory perception related to homonymous hemianopsia. Early in the care of the patient, what should the nurse do?

a. Place objects on the right side within the patient’s field of vision.
b. Approach the patient from the left side to encourage the patient to turn the head.
c. Place objects on the patient’s left side to assess the patient’s ability to compensate.
d. Patch the affected eye to encourage the patient to turn the head to scan the environment.

Answer 4

a. Place objects on the right side within the patient’s field of vision.

The presence of homonymous hemianopia in a patient with right hemisphere brain damage causes a loss of vision in the left field bilaterally. Early in the care of the patient, objects should be placed on the right side of the patient in the field of vision and the nurse should approach the patient from the right side. Later in treatment, patients should be taught to turn the head and scan the environment and should be approached from the affected side to encourage head turning. Eye patches are used if patients have diplopia (double vision).

Question 5

Four days following a stroke, a patient is to start oral fluids and feedings. Before feeding the patient, what should the nurse do first?

a. Check the patient’s gag reflex.
b. Order a soft diet for the patient.
c. Raise the head of the bed to a sitting position.
d. Evaluate the patient’s ability to swallow small amounts of crushed ice or ice water.

Answer 5

a. Check the patient’s gag reflex.

Usually the speech therapist will have completed a swallowing study before a diet is ordered. The first step in providing oral feedings for a patient with a stroke is ensuring that the patient has an intact gag reflex because oral feedings will not be provided if the gag reflex is impaired. After placing the patient in an upright position, the nurse should then evaluate the patient’s ability to swallow ice chips or ice water.

Question 6

What is an appropriate food for a patient with a stroke who has mild dysphagia?

a. Fruit juices
b. Pureed meat
c. Scrambled eggs
d. Fortified milkshakes

Answer 6

c. Scrambled eggs

Soft foods that promote enough texture, flavor, and bulk to stimulate swallowing should be used for the patient with dysphagia. Thin liquids are difficult to swallow and patients may not be able to control them in the mouth. Pureed foods are often too bland and too smooth and milk products should be avoided because they tend to increase the viscosity of mucus and increase salivation.

Question 7

A patient’s wife asks the nurse why her husband did not receive the clot busting medication (tissue plasminogen activator [tPA] she has been reading about. Her husband is diagnosed with a hemorrhagic stroke. What is the best response by the nurse to the patient’s wife?

a. “He didn’t arrive within the timeframe for that therapy.”
b. “Not everyone is eligible for this drug. Has he had surgery lately?”
c. “You should discuss the treatment of your husband with his doctor.”
d. “The medication you are talking about dissolves clots and could cause more bleeding in your husband’s brain.”

Answer 7

d. “The medication you are talking about dissolves clots and could cause more bleeding in your husband’s brain.”

Recombinant tissue plasminogen activator (tPA) dissolves clots and increases the risk for bleeding. It is not used with hemorrhagic strokes. If the patient had a thrombotic or embolic stroke, the timeframe of 3 to 4.5 hours after onset of clinical signs of the stroke would be important as well as a history of surgery. The nurse should answer the question as accurately as possible and then encourage the wife to talk with the physician if she has further questions.

Question 8

The rehabilitation nurse assesses the patient, caregiver, and family before planning the rehabilitation program for this patient. What needs to be included in this assessment (select all that apply)?

a. Cognitive status of the family
b. Patient resources and support
c. Rehabilitation potential of the patient
d. Body strength remaining after the stroke
e. Physical status of body systems affected by the stroke
f. Patient and caregiver expectations of the rehabilitation

Answer 8

a. Cognitive status of the family
d. Body strength remaining after the stroke
e. Physical status of body systems affected by the stroke
f. Patient and caregiver expectations of the rehabilitation

The patient’s rehabilitation potential and expectations of the patient and caregiver related to the rehabilitation program will have a big impact on planning and carrying out the rehabilitation plan. The other things the rehabilitation nurse will assess are the physical status of all the patient’s body systems, presence of complications caused by the stroke or other chronic conditions, the cognitive status of the patient, and the family (including the patient and caregiver) resources and support.

Question 9

What is an appropriate nursing intervention to promote communication during rehabilitation of the patient with aphasia?

a. Use gestures, pictures, and music to stimulate patient responses.
b. Talk about activities of daily living (ADLs) that are familiar to the patient.
c. Structure statements so that the patient does not have to respond verbally.
d. Use flashcards with simple words and pictures to promote recall of language.

Answer 9

b. Talk about activities of daily living (ADLs) that are familiar to the patient.

During rehabilitation, the patient with aphasia needs frequent, meaningful verbal stimulation that has relevance for him or her. Conversation by the nurse and family should address activities of daily living (ADLs) that are familiar to the patient. Gestures, pictures, and simple statements are more appropriate in the acute phase, when patients may be overwhelmed by verbal stimuli. Flashcards are often perceived by the patient as childish and meaningless. Not responding verbally does not promote communication.

Question 10

A patient with a right hemisphere stroke has a nursing diagnosis of unilateral neglect related to sensory-perceptual deficits. During the patient’s rehabilitation, what nursing intervention is important for the nurse to do?

a. Avoid positioning the patient on the affected side.
b. Place all objects for care on the patient’s unaffected side.
c. Teach the patient to care consciously for the affected side.
d. Protect the affected side from injury with pillows and supports.

Answer 10

c. Teach the patient to care consciously for the affected side.

Unilateral neglect, or neglect syndrome, occurs when the patient with a stroke is unaware of the affected side of the body, which puts the patient at risk for injury. During the acute phase, the affected side is cared for by the nurse with positioning and support but during rehabilitation the patient is taught to care consciously for and attend to the affected side of the body to protect it from injury. Patients may be positioned on the affected side for up to 30 minutes.

Question 11

A patient with a stroke has a right-sided hemiplegia. What does the nurse teach the family to prepare them to cope with the behavior changes seen with this type of stroke?

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.

Answer 11

c. Distract the patient from inappropriate emotional responses.

Patients with left-brain damage from stroke often experience emotional lability, inappropriate emotional responses, mood swings, and uncontrolled tears or laughter disproportionate to 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. Maintaining a calm environment and avoiding shaming or scolding the patient is important. Patients with right-brain damage often have impulsive, rapid behavior that requires supervision and direction.

Question 12

The nurse can assist the patient and family in coping with the long-term effects of a stroke by doing what?

a. Informing family members that the patient will need assistance with almost all ADLs
b. Explaining that the patient’s prestroke behavior will return as improvement progresses
c. Encouraging the patient and family members to seek assistance from family therapy or stroke support groups
d. Helping the patient and family to understand the significance of residual stroke damage to promote problem solving and planning

Answer 12

d. Helping the patient and family to understand the significance of residual stroke damage to promote problem solving and planning

The patient and family need accurate and complete information about the effects of the stroke to problem-solve and make plans for the chronic care of the patient. It is uncommon for patients with major strokes to return completely to prestroke function, behaviors, and role and both the patient and family will mourn these losses. The patient’s specific needs for care must be identified and rehabilitation efforts should be continued at home. Family therapy and support groups may be helpful for some patients and families.

Question 13

For a patient who is suspected of having a stroke, one of the most important pieces of information that the nurse can obtain is

a. time of the patient’s last meal.
b. time at which stroke symptoms first appeared.
c. patient’s hypertension history and management.
d. family history of stroke and other cardiovascular diseases.

Answer 13

b. time at which stroke symptoms first appeared.

During initial evaluation, the most important point in the patient’s history is the time since onset of stroke symptoms. If the stroke is ischemic, recombinant tissue plasminogen activator (tPA) must be administered within 3 to 4.5 hours of the onset of clinical signs of ischemic stroke; tPA reestablishes blood flow through a blocked artery and prevents brain cell death in patients with acute onset of ischemic stroke.

Question 14

Bladder training in a male patient who has urinary incontinence after a stroke includes

a. limiting fluid intake.
b. keeping a urinal in place at all times.
c. assisting the patient to stand to void.
d. catheterizing the patient every 4 hours.

Answer 14

c. assisting the patient to stand to void.

In the acute stage of stroke, the primary urinary problem is poor bladder control and incontinence. Nurses should promote normal bladder function and avoid the use of indwelling catheters. A bladder retraining program consists of (1) adequate fluid intake, with most fluids administered between 7:00 AM and 7:00 PM; (2) scheduled toileting every 2 hours with the use of a bedpan, commode, or bathroom; and (3) noting signs of restlessness, which may indicate the need for urination. Intermittent catheterization may be used for urinary retention (not urinary incontinence). During the rehabilitation phase after a stroke, nursing interventions focused on urinary continence include (1) assessment for bladder distention by palpation; (2) offering the bedpan, urinal, commode, or toilet every 2 hours during waking hours and every 3 to 4 hours at night; (3) using a direct command to help the patient focus on the need to urinate; (4) assistance with clothing and mobility; (5) scheduling most fluid intake between 7:00 AM and 7:00 PM; and (6) encouraging the usual position for urinating (i.e., standing for men and sitting for women).

Question 15

Common psychosocial reactions of the stroke patient to the stroke include (select all that apply)

a. depression.
b. disassociation.
c. intellectualization.
d. sleep disturbances.
e. denial of severity of stroke.

Answer 15

a. depression.
d. sleep disturbances.
e. denial of severity of stroke.

The patient with a stroke may experience many losses, including sensory, intellectual, communicative, functional, role behavior, emotional, social, and vocational losses. Some patients experience long-term depression, manifesting symptoms such as anxiety, weight loss, fatigue, poor appetite, and sleep disturbances. The time and energy required to perform previously simple tasks can result in anger and frustration. Frustration and depression are common in the first year after a stroke. A stroke is usually a sudden, extremely stressful event for the patient, caregiver, family, and significant others. The family is often affected emotionally, socially, and financially as their roles and responsibilities change. Reactions vary considerably but may involve fear, apprehension, denial of the severity of stroke, depression, anger, and sorrow.

Question 16

A female patient has left-sided hemiplegia following an ischemic stroke that she experienced 4 days earlier. How should the nurse best promote the health of the patient’s integumentary system?

a. Position the patient on her weak side the majority of the time.
b. Alternate the patient’s positioning between supine and side-lying.
c. Avoid the use of pillows in order to promote independence in positioning.
d. Establish a schedule for the massage of areas where skin breakdown emerges.

Answer 16

b. Alternate the patient’s positioning between supine and side-lying.

A position change schedule should be established for stroke patients. An example is side-back-side, with a maximum duration of 2 hours for any position. The patient should be positioned on the weak or paralyzed side for only 30 minutes. Pillows may be used to facilitate positioning. Areas of skin breakdown should never be massaged.

Question 17

The patient with diabetes mellitus has had a right-sided stroke. Which nursing intervention should the nurse plan to provide for this patient related to expected manifestations of this stroke?

a. Safety measures
b. Patience with communication
c. Mobility assistance on the right side
d. Place food in the left side of patient’s mouth.

Answer 17

a. Safety measures

A patient with a right-sided stroke has spatial-perceptual deficits, tends to minimize problems, has a short attention span, is impulsive, and may have impaired judgment. Safety is the biggest concern for this patient. Hemiplegia occurs on the left side of this patient’s body. The patient with a left-sided stroke has hemiplegia on the right, is more likely to have communication problems, and needs mobility assistance on the right side with food placed on the left side if the patient needs to be fed after a swallow evaluation has taken place.

Question 18

The nurse is planning psychosocial support for the patient and family of the patient who suffered a stroke. What factor will most likely have the greatest impact on positive family coping with the situation?

a. Specific patient neurologic deficits
b. The patient’s ability to communicate
c. Rehabilitation potential of the patient
d. Presence of complications of a stroke

Answer 18

c. Rehabilitation potential of the patient

Although a patient’s neurologic deficit might initially be severe after a stroke, the ability of the patient to recover is most likely to positively impact the family’s coping with the situation. Providing explanations and emotional support beginning in the acute phase through the rehabilitation phase will facilitate coping. Emphasizing successes will offer the most realistic hope for the patient’s rehabilitation and helps maintain hope for the patient’s future abilities.

Question 19

A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing prevention is priority?

1. Prepare to administer recombinant tissue plasminogen activator (rt-PA).
2. Discuss the precipitating factors that caused the symptoms.
3. Schedule for a STAT computed tomography (CT) scan of the head.
4. Notify the speech pathologist for an emergency consult.

Answer 19

3. Schedule for a STAT computed tomography (CT) scan of the head.

A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. If a CVA is diagnosed, the CT scan can determine if it is a hemorrhagic or ischemic accident and guide treatment.

Question 20

The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge?

1. An oral anticoagulant medication.
2. A beta blocker medication.
3. An anti-hyperuricemic medication.
4. A thrombolytic medication.

Answer 20

1. An oral anticoagulant medication.

The nurse would anticipate an oral anticoagulant, warfarin (Coumadin), to be prescribed to help prevent thrombi formation in the atria secondary to atrial fibrillation. The thrombi can become embolic and may cause a TIA or CVA (stroke).

Question 21

The 85-year-old client diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first?

1. Administer a nonnarcotic analgesic.
2. Prepare for STAT magnetic resonance imaging (MRI).
3. Start an intravenous infusion with D5W at 100 mL/hr.
4. Complete a neurological assessment.

Answer 21

4. Complete a neurological assessment.

The nurse must complete a neurological assessment to help determine the cause of the headache before taking any further action.

Question 22

A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement?

1. Administer a stool softener b.i.d.
2. Encourage the client to cough hourly.
3. Monitor the neurological status every shift.
4. Maintain the dopamine drip to keep BP at 160/90.

Answer 22

1. Administer a stool softener b.i.d.

The client is at risk for increased intracranial pressure whenever performing the Valsalva maneuver, which will occur when straining during defecation. Therefore, stool softeners would be appropriate.

Question 23

The client diagnosed with a right-sided cerebrovascular accident (CVA) is admitted to the rehabilitation unit. Which priority intervention should be included in the nursing care plan?

1. Position the client to prevent shoulder adduction.
2. Set up the client’s tray during meals.
3. Turn and reposition the client every shift.
4. Refer the client to an occupational therapist.

Answer 23

1. Position the client to prevent shoulder adduction.

Placing a small pillow under the shoulder will prevent the shoulder from adducting toward the chest and developing a contracture. This is priority because it is a physiological need.

Question 24

A client with a stroke has dysphagia. Before allowing the client to eat, which of the following actions should the nurse take first?

a. Check the client’s gag reflex.
b. Request a soft diet with no liquids.
c. Place the client in high fowler’s position.
d. Test the client’s ability to swallow with a small amount of water.

Answer 24

a. Check the client’s gag reflex.

Question 25

A client with right sided paresthesias and hemiparesis is hospitalized and diagnosed with a thrombotic stroke. Over the next 72 hours, the nurse plans care with the knowledge that the client:

a. Is ready for aggressive rehabilitation.
b. Will show gradual improvement of the initial neurological deficits.
c. May show signs of deteriorating neurological function as cerebral edema increases.
d. Should not be turned or exercised to prevent extension of the thrombus and increased neurological deficits

Answer 25

c. May show signs of deteriorating neurological function as cerebral edema increases.

Question 26

A newly admitted client diagnosed with a right-brain stroke has a nursing diagnosis of disturbed visual sensory perception related to homonymous hemianopsia. Early in the care of the client, what should the nurse do?

a. Place objects on the right side within the client’s field of vision.
b. Approach the client from the left side to encourage the client to turn the head.
c. Place objects on the client’s left side to assess the client’s ability to compensate.
d. Patch the affected eye to encourage the client to turn the had to scan the environment.

Answer 26

a. Place objects on the right side within the client’s field of vision.

Question 27

The nurse is preparing to administer acetaminophen (Tylenol) to a client diagnosed with a stroke who is complaining of a headache. Which intervention should the nurse implement first?

a. Administer the medication in pudding.
b. Check the client’s armband.
c. Crush the tablet and dissolve in juice.
d. Have the client sip some water.

Answer 27

d. Have the client sip some water.

Asking the client to sip some water assesses the client’s ability to swallow, which is a priority when placing anything in the mouth of the client who has had a stroke. The armband should be checked but not before determining if the client can swallow.