The Client with a Stroke

Question 1

Which outcomes indicate effective management of a conscious client who is being treated with recombinant tissue plasminogen therapy during the initial phase of an ischemic cerebral vascular accident (CVA)? SATA

1. headache reduced
2. dysphagia improved
3. visual disturbances improved
4. responds to comfort measures
5. no signs or symptoms of bleeding

Answer 1

1. headache reduced
2. responds to comfort measures
3. no signs or symptoms of bleeding

A headache is commonly associated with an ischemic CVA.
A conscious client responds to comfort measures.
Bleeding is a side effect of recombinant tPA therapy to dissolve the clots; absence of bleeding is a desired outcome.

Reduction of dysphagia and visual disturbances is unpredictable and less likely to occur during this phase.

Question 2

Following a stroke, a client has dysphagia and left-sided facial paralysis. Which feeding technique will be most helpful at this time?

1. Encourage sipping diluted liquid meal supplements from a straw
2. Position the client with the bed at a 30 degree angle
3. Offer solid foods from the unaffected side of the mouth
4. Feed the client a soft diet from a spoon into the left side of the mouth

Answer 2

3. Offer solid foods from the unaffected side of the mouth

Following a stroke, it is easiest for clients with dysphagia to swallow solid foods.

Liquid foods are difficult to swallow and the client with facial paralysis will have difficulty sipping using a straw. The HOB is elevated 90 degrees or the client is instructed to sit up, if possible, while eating to prevent choking and aspiration.

Question 3

The nurse is teaching a client about taking prophylactic warfarin sodium. Which statement indicates that the client understands how to take the drug? SATA

1. “The drug’s action peaks in 2 hours”
2. “Maximum dosage is not achieved until 3 to 4 days after starting the medication”
3. “Effects of the drug continue for 4 to 5 days after discontinuing the medication”
4. “Protamine sulfate is the antidote for warfarin”
5. “I should have my blood levels tested periodically.”

Answer 3

2. “Maximum dosage is not achieved until 3 to 4 days after starting the medication”
3. “Effects of the drug continue for 4 to 5 days after discontinuing the medication”
4. “I should have my blood levels tested periodically.”

Warfarin has a peak action of 9 hours. Vitamin K is the antidote for warfarin; protamine sulfate is the antidote for heparin.

Question 4

A client arrives in the ED with an ischemic stroke. What should the nurse do before the client receives TPA

1. Ask what medications the client is taking
2. Complete a history and health assessment
3. Identify the time of onset of the stroke
4. Determine if the client is scheduled for any surgical procedures

Answer 4

3. Identify the time of onset of the stroke

Studies show that clients who receive recombinant tPA treatment within 3 hours after the onset of a stroke have better outcomes.

Question 5

A client has received thrombolytic treatment for as ischemic stroke. The nurse should notify the HCP is there is a rapid increase in which vital sign?

1. pulse
2. respirations
3. blood pressure
4. temperature

Answer 5

3. blood pressure

Control of blood pressure is critical during the first 24 hours after treatment because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy.

Vital signs are monitored, and bp is maintained as identified by the HCP and specific to the client’s ischemic tissue needs and risk of bleeding from treatment. The other vital signs are important, but the priority is to monitor BP

Question 6

What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke?

1. cholesterol level
2. pupil size and pupillary response
3. bowel sounds
4. echocardiogram

Answer 6

2. pupil size and pupillary response

It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves.

An echocardiogram is not needed for the client with a thrombotic stroke without heart problems.

Question 7

A client with a hemorrhagic stroke is slightly agitated, hr is 118 bpm, rr are 22 breaths/min, bilateral rhonchi are auscultated, spo2 is 94%, bp is 144/88 mmHg, and oral secretions are noted. What order of interventions from first to last should the nurse follow when suctioning the client to prevent increased ICP and maintain adequate cerebral perfusion?

1. Suction the airway
2. Hyperoxygenate
3. Suction the mouth
4. Provide sedation

Answer 7

4, 2, 1, 3

Increased agitation with suctioning will increase ICP; therefore, sedation should be provided first. The client should be hyperoxygenated before and after suctioning to prevent hypoxia since hypoxia causes vasodilation of the cerebral vessels and increased ICP. The airway should then be suctioned for no more than 10 seconds. The mouth can be suctioned once the airway is clear to remove oral secretions. Once the mouth is suctioned, the suction catheter should be discarded.

Question 8

Which positioning technique is most effective when there is only one person to assist the client to move from the left side to the right side if the client has hemiparalysis?

1. rolling the client onto the side
2. sliding the client move up in bed
3. lifting the client when moving the client up in bed
4. having the client help life off the bed using a trapeze

Answer 8

1. rolling the client onto the side

Rolling the client is the most effective method to use when there is only one person to help the client change positions from one side to another.

The nurse must keep the client in anatomically neutral positions and ensure that the limbs are properly supported. Sliding a client on a sheet causes friction and is to be avoided. Friction injures skin and predisposes to pressure ulcer formation. The client may be lifted as long as the nurse has assistance and uses proper body mechanics to avoid injury. Having the client lift off the bed with a trapeze is an acceptable means to move a client when the client needs use the bedpan or lie on the back.

Question 9

Which is the most effective means of preventing plantar flexion in a client who has had a stroke with residual paralysis?

1. Place the client’s feet against a firm footboard
2. Reposition the client every 2 hours
3. Have the client wear ankle-high tennis shoes at intervals throughout the day.
4. Massage the client’s feet and ankles regularly.

Answer 9

3. Have the client wear ankle-high tennis shoes at intervals throughout the day.

The use of ankle-high tennis shoes has been found to be most effective in preventing plantar flexion (footdrop) because they add support to the foot and keep it in the correct anatomic position.

Regular repositioning and ROM exercises are important interventions, but the client’s food needs to be in the correct anatomic position to prevent overextension of the muscle and tendon.

Question 10

The nurse is planning the care of a hemiplegic client to prevent joint deformities of the arm and hand. Which position is appropriate? SATA

1. placing a pillow in the axilla so the arm is away from the body
2. inserting a pillow under the slightly flexed arm so the hand is higher than the elbow
3. immobilizing the extremity in a sling
4. positioning a hand cone in the hand so the fingers are barely flexed
5. keeping the arm at the side using a pillow

Answer 10

1. placing a pillow in the axilla so the arm is away from the body
2. inserting a pillow under the slightly flexed arm so the hand is higher than the elbow
3. positioning a hand cone in the hand so the fingers are barely flexed

Placing a pillow in the axilla so the arm is away from the body keeps the arm abducted and prevents skin from touching skin to avoid skin breakdown. Placing a pillow under the slightly flexed arm so the hand is higher than the elbow prevents dependent edema. Positioning a hand cone in the hand prevents hand contractures.

Question 11

The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which strategies should the nurse include in the teaching plan? SATA

1. maintaining an upright position while eating
2. restricting the diet to liquids until swallowing improves
3. introducing foods on the unaffected side of the mouth
4. keeping distractions to a minimum
5. cutting food into large pieces of finger food

Answer 11

1. maintaining an upright position while eating
2. introducing foods on the unaffected side of the mouth
3. keeping distractions to a minimum

Question 12

The nurse is assisting a client with a stroke who has homonymous hemianopia. The nurse should understand that the client will do which when eating?

1. Have a preference for foods high in salt
2. Eat food on only half of the place
3. Forget the names of foods
4. Be unable to swallow liquids

Answer 12

2. Eat food on only half of the place

Homonymous hemianopia is blindness in half of the visual field; therefore the client would see only half of the plate.

Question 13

A client is experiencing mood swings after a stroke and often has episodes of tearfulness that are distressing to the family. Which is the best technique for the nurse to instruct family members to try when the client experiences a crying episode?

1. Sit quietly with the client until the episode is over
2. Ignore the behavior
3. Attempt to divert the client’s attention
4. Tell the client that this behavior is unacceptable

Answer 13

3. Attempt to divert the client’s attention

A client who has brain damage may be emotionally labile and may cry or laugh for no explainable reason. Crying is best dealt with by attempting to divert the client’s attention.

Question 14

When communication with a client who has aphasia, which approaches are helpful? SATA

1. Present one thought at a time
2. Avoid writing messages
3. Speak with normal volume
4. Make use of gestures.
5. Encourage pointing to the needed object

Answer 14

1. Present one thought at a time
2. Speak with normal volume
3. Make use of gestures.
4. Encourage pointing to the needed object

The goal of communicating with a client with aphasia is to minimize frustration and exhaustion.