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