Stroke

Question 0

Chronic blood pressure can cause what kind of stroke

Answer 0

Hemmorage stroke

Question 1

Stroke assessment

Answer 1

Family history, personal history, loc and orientation, memory- remote or long term, recall, immediate,attention,language and copying, drug use,meds,psych hx, bleeding problems,chronic Bp

Question 2

Sensory function in stroke assessment

Answer 2

Pain, temp,

Question 3

Romberg sign

Answer 3

Standing with legs together eyes closed and staying up right..knowing your core proiosection

Question 4

Reflex assessment

Answer 4

Hyperactive-upper motor neuron issue. Hypo active- spinal cord issue

Question 5

Decorticate

Answer 5

“Towards the core” happens when doing sternal rub to traumatic Brain injury , possibly reversible

Question 6

Decerebrate

Answer 6

Rigidity,extension of arms,legs,plantar flexion happens during sternal rub and most likely not reversible

Question 7

Lab test for stroke pt

Answer 7

Blood cultures for change in loc, skull and spine X-ray,cerebral angiography,ct always with out dye, pet scan

Question 8

NIH STROKE SCALE

Answer 8

LOC QUESTIONS AND COMMANDS,BEST GAZE VISUAL FACIAL PALSY MOTOR LEG/ARM LIMB ATAXIA BEST LANGUAGE DYSARTHRIA NEGLECT

Question 9

Ischemic stroke

Answer 9

Embolism-a fib thrombotic carotid artery atherosclerosis. 8-12 hours to show up on ct can have tpa if meet requirements and under 180 min

Question 10

Tia

Answer 10

Mini stroke actual can happen usually 2 days after its a warning sign to a stroke and a temporary blockage

Question 11

Thrombolytic therapy

Answer 11

Can only be given up to 180 minutes could be extended to 4 1/2 hours . No antiplatlets for 24 hours avoid dextrose solutions manual Bp only no rectal temp elevate hob npo until speech swallow eval purée meals after loc before meals placed on fall risk and skin breakdown BLEEDING PRECAUTIONS WATCH FOR SUDDEN SEVERE HEADACHE COULD BE FROM INCREASED INTERCRANIAL PRESSURE one Venus puncture per day nursing intervened = bleeding precautions intervened to prevents aspiration and preventable safety precautions

Question 12

Hemorrhagic stroke

Answer 12

Ruptured aneurysm or av malformation

Question 13

Av malformation

Answer 13

Usually have multiple and treated with gama radiation occlude abnormal arteries or veins

Question 14

Epidural hemorrhage

Answer 14

Most dangerous headache then loc in 5 min regain loc tremendous headache disorientation out again

Question 15

Risk factors for ischemic stroke

Answer 15

Htn, atherosclerosis, dm, a fib, Tia, smoking , oral contraceptives, obesity,

Question 16

Risk for hemorrhagic stroke

Answer 16

Cocaine use cerebral aneurysm av malformation

Question 17

Left side of brain stroke

Answer 17

Language , math skills and analytical thinking

Question 18

Right hemisphere

Answer 18

Visual spatial awareness propriception

Question 19

Left hemisphere stroke

Answer 19

Aphasia alexia agraphia slow cautious behavior depression and quick frustration visual changes

Question 20

Right hemisphere stroke

Answer 20

Unaware of deficits loss of depth perception disorientation impulse control diffculty poor judgement visual changes

Question 21

Broccas area

Answer 21

Speech center

Question 22

Wernikes area

Answer 22

Written or spoken word area

Question 23

Brain steam stroke

Answer 23

Bled blood pressure respiratory rate balance coordination speech and swallowing nausea and dizziness

Question 24

Cerebellum stroke

Answer 24

Balance coordination

Question 25

Nursing diagnosis

Answer 25

Ineffective tissue perfusion in disturb sensory perception impaired physical mobility a unilateral neglect risk for injury self-care deficit impaired verbal communication impaired swallowing

Question 26

Nursing assessment

Answer 26

Airway patency swallowing ability aspiration risk airway breathing vital signs hyperthermia lower than 99.5° neurological status level of consciousness Glasgow’s coma scale motor function sensory function stroke associate in the Mont yeah and UTI

Question 27

Nursing interventions

Answer 27

Maintain pay in airway monitor for changes in level of consciousness’s elevate head of bed to decrease intracranial pressure Cesar precaution everyone at risk with stroke non-stimulating environment Q munication skills say feeding treat fevers less then 99° high both their Mia is associated withPoor outcomes maintain skin integrity passive and active range of motion emotion every two hours all of the affected extremity maintain safe environment fall prevention’s scanning technique DVT prevention and immobility meds ADLs referrals

Question 28

Shoulder safety

Answer 28

Initially the affected arm of a stroke should always be supported it is said that shoulder problems affect 70% of stroke patients gravity can act as a way in Sue blocks the shoulder joint stroke patient should not be pulled or guided by their affected arm

Question 29

Neglect

Answer 29

The patient is unaware that a body part or side of the body is there the side of the body maybe flaccid patient likely will let lean to the side of neglect patient will often bump into objects with that side of the body sit or stand on the side of the body the patient is neglecting this will force them to turn their head to look at you place calendar pictures flowers etc. on the side of neglectso patient will become accustomed to scanning or looking to that side

Question 30

clinical presentation for initiation of stroke team

Answer 30

Aphasia expressive receptive or global ataxia crane on nerve palsy facial droop diplopia dysrhythmia how many Paris thesis loss of sensation hemi Paris sees his or her Quadra Pearcy sis visual field disturbances

Question 31

Stroke center goals

Answer 31

Door to dock 10 minutes door to CT 25 minutes door to CT reading 45 minutes door to drug 60 minutes

Question 32

Expressive aphasia

Answer 32

Brokas or motor

Question 33

Receptive aphasia

Answer 33

Wernecke’s or sensory

Question 34

Dysphasia

Answer 34

Impaired swallowing three types of diagnostic testing initials screening test identifies likely presence of dysphasia completed by bedside clinician more comprehensive test administered by train Swalling clinician instrumental testing gold standard

Question 35

Bedside dysphasia screening

Answer 35

Alert enough to participate in the evaluation face is symmetric with out any droop no drooling or dried oral secretions does not require and T or oral suctioning able to cough reflectively oh or if asked cough is neither week nor what test the gag with a tongue depressor or if the gag is this diminished or absent score now swallows his own secretions spontaneously voice is neither week not wet or a gurgly can move his/her tongue up and down and side to side when asked swallowing of 2 teaspoons of water thickened if patient’s normal diet failure if struggling to swallow cough choking loss of fluid from mouth change in vocal quality wet/gurgly it failed either bedside screening or swallowing evaluation and PO and referral to speech pathology if past bedside a valuation in swallowing a valuation referral to speech pathology initiate. Diet with nectar thick liquid’s medications crushed in Pieriel if possible