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Medical Language Accelerated2nd EditionAndrew Cavanagh, Steven Jones 568 solutions 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. A 72-year-old patient who has a history of a transient
ischemic attack (TIA) has an order foraspirin 160 mg daily. When the nurse is administering medications, the patient says, "I don'tneed the aspirin today. I don't have a fever." Which action should the nurse take? c. Explain that the aspirin is ordered to decrease stroke risk. Aspirin is ordered to prevent stroke in patients who have experienced TIAs. Documentation ofthe patient's refusal to take the medication is an inadequate response by the nurse. There is noneed to clarify the order with the health care provider. The aspirin is not ordered to preventaches and pains. For a patient who had a right hemisphere stroke the nurse
establishes a nursing diagnosis of a. risk for injury related to denial of deficits and impulsiveness. The patient with right-sided brain damage typically denies any deficits and has poor impulsecontrol, leading to risk for injury when the patient attempts activities such as transferring froma bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damagetypically causes language deficits. Left-sided brain damage is associated with depression anddistress about the disability. During the change of shift report a nurse is told that a patient has an occluded left posteriorcerebral
artery. The nurse will anticipate that the patient may have c. visual deficits. Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs withmiddle cerebral artery involvement. Cognitive deficits and changes in judgment are moretypical of anterior cerebral artery occlusion A patient with a history
of several transient ischemic attacks (TIAs) arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. The nurse anticipates the need to prepare the patient for d. tissue plasminogen activator (tPA) infusion. The patient's history and clinical manifestations suggest an acute ischemic stroke and a patient who is seen within 4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is having an acute ischemic stroke. A patient has a stroke affecting the right hemisphere of the brain. Based on knowledge of the
effects of right brain damage, the nurse establishes a nursing diagnosis of b. risk for injury related to denial of deficits and impulsiveness. Right-sided brain damage typically causes denial of any deficits and poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability. 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? 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. What is an appropriate food for a patient with a stroke who has mild dysphagia? a. Fruit juices 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 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. 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). 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 The nurse observes a student nurse assigned to initiate oral feedings for a 68-yr-old woman with an ischemic stroke. Which action by the student will require the nurse to intervene? A. giving the pt 1 oz of water to swallow B. telling the pt to perform a chin tuck before swallowing C. assisting the pt to sit in a chair before feeding the pt D. assessing cranial nerves III, IV, and VI before attempting feeding D. assessing cranial nerves III, IV, and VI before attempting feeding A female patient has left-sided hemiplegia after an ischemic stroke 4 days earlier. How should the nurse promote skin integrity? 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 B. alternate the patient's positioning between supine and side-lying A 74-yr-old man who has right-sided extremity paralysis related to a thrombotic stroke develops constipation. Which action should the nurse ask first? A. assist the patient to the bathroom every 2 hours B. provide incontinence briefs to wear during the day C. administer a bisacodyl (Dulcolax) rectal suppositiory every day D. arrange for several servings per day of cooked fruits and vegetables D. arrange for several servings per day of cooked fruits and vegetables 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. 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. The nurse is planning psychosocial support for the family of the patient who suffered a stroke. What factor will have the greatest impact on family coping? A. specific patient neurologic defects B. the patient's ability to communicate C. rehabilitation potential of the patient D. presence of complications of a stroke C. rehabilitation potential of the patient Which sensory-perceptual deficit is associated with left-sided stroke (right hemiplegia)? A. Overestimation of physical abilities. B. Difficulty judging position and distance. C. Slow and possibly fearful performance of tasks. D. Impulsivity and impatience at performing tasks. C. Slow and possibly fearful performance of tasks. The nurse is discharging a patient admitted with a transient ischemic attack (TIA). For which medications might the nurse expect to provide discharge instructions (select all that apply)? A. Ticlopidine B. Clopidogrel C. Enoxaparin D. Dipyridamole E. Enteric-coated aspirin F. Tissue plasminogen activator (TPA) A. Ticlopidine The female patient has been brought to the emergency department complaining of the most severe headache of her life. Which type of stroke should the nurse anticipate? A. TIA B. embolic stroke C. thrombotic stroke D. Hemorrhagic CVA D. Hemorrhagic CVA The nurse would expect to find what clinical manifestation in a patient admitted with a left-sided stroke? A. impulsivity B. impaired speech C. left-side neglect D. short attention span B. impaired speech The patient with diabetes mellitus had a right-sided stroke. Which nursing intervention should the nurse plan to provide for this patient? A. safety measures B. patience with communication C. mobility assistance on the right side D. place food in the left side of the patient's mouth A. safety measures Which intervention is most appropriate when communicating with a patient with aphasia after a stroke? A. present several thoughts at once so that the patient can connect ideas B. ask open-ended questions to provide the patient the opportunity to speak C. finish the patient's sentences to minimize frustration associated with slow speech D. use simple, short sentences accompanied by visual cues to enhance comprehension D. use simple, short sentences accompanied by visual cues to enhance comprehension The nurse in a primary care provider's office is assessing several patients today. Which patient is most at risk for a stroke? A. A 92-yr-old female patient who take warfarin (Coumadin) for atrial fibrillation B. A 28-yr-old male patient who uses marijuana after chemotherapy to control nausea C. A 42-yr-old female patient who takes oral contraceptives and has migraine headaches D. A 72-yr-old male patient who has hypertension and diabetes mellitus and smoke tobacco D. A 72-yr-old male patient who has hypertension and diabetes mellitus and smoke tobacco The nurse expects that management of the patient who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects will include a. prophylactic clipping of cerebral aneurysms. b. heparin via continuous intravenous infusion. c. oral administration of low dose aspirin therapy. d. therapy with tissue plasminogen activator (tPA). c. oral administration of low dose aspirin therapy. The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA. Aspirin is ordered for a patient who is admitted with a possible stroke. Which information obtained during the admission assessment indicates that the nurse should consult with the health care provider before giving the aspirin? a. The patient has dysphasia. b. The patient has atrial fibrillation. c. The patient states, My symptoms started with a terrible headache. d. The patient has a history of brief episodes of right-sided hemiplegia. C. The patient states, My symptoms started with a terrible headache A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack (TIA) are not contraindications to aspirin use, so the nurse can administer the aspirin. GOOD ONE A patient with a stroke experiences right-sided arm and leg paralysis and facial drooping on the right side. When admitting the patient, which clinical manifestation will the nurse expect to find? a. Impulsive behavior b. Right-sided neglect c. Hyperactive left-sided reflexes d. Difficulty in understanding commands d. difficulty in understanding commands Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty withcomprehension and use of language. The left-side reflexes are likely to be intact. Impulsivebehavior and neglect are more likely with a right-side stroke. Good one A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergencydepartment and diagnostic tests are ordered. Which test should be done first? d. Noncontrast computed tomography (CT) scan Rapid screening with a noncontrast CT scan is needed before administration of tissueplasminogen activator (tPA), which must be given within 4.5 hours of the onset of clinicalmanifestations of the stroke. The sooner the tPA is given, the less brain injury. The otherdiagnostic tests give information about possible causes of the stroke and do not need to becompleted as urgently as the CT scan. A 58-year-old patient with a left-brain stroke suddenly bursts into tears when family membersvisit. The nurse should d. teach the family that emotional outbursts are common after strokes. Patients who have left-sided brain stroke are prone to emotional outbursts that are notnecessarily related to the emotional state of the patient. Depression after a stroke is common,but the suddenness of the patient's outburst suggests that depression is not the major cause ofthe behavior. The family should stay with the patient. The crying is not within the patient'scontrol and asking the patient to stop will lead to embarrassment. The nurse receives a verbal report that a patient has an occlusion of the left posterior cerebral artery. The nurse will anticipate that the patient may have a. dysphasia. b. confusion. c. visual deficits. d. poor judgment. c. visual deficits GOOD ONE The health care provider prescribes clopidogrel (Plavix) for a patient with cerebral atherosclerosis. When teaching about the new medication, the nurse will tell the patient a. to monitor and record the blood pressure daily. b. to call the health care provider if stools are tarry. c. that Plavix will dissolve clots in the cerebral arteries. d. that Plavix will reduce cerebral artery plaque formation. b. to call the health care provider if stools are tarry Plavix inhibits platelet function and increases the risk for gastrointestinal bleeding, so patients should be advised to notify the health care provider about any signs of bleeding. The medication does not lower blood pressure, decrease plaque formation, or dissolve clots. A patient with a history of several transient ischemic attacks (TIAs) arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. The nurse anticipates the need to prepare the patient for a. surgical endarterectomy. b. transluminal angioplasty. c. intravenous heparin administration. d. tissue plasminogen activator (tPA) infusion. d. tissue plasminogen activator (tPA) infusion. The nurse identifies the nursing diagnosis of impaired verbal communication for a patient with expressive aphasia. An appropriate nursing intervention to help the patient communicate is to a. have the patient practice facial and tongue exercises. b. ask simple questions that the patient can answer with yes or no. c. develop a list of words that the patient can read and practice reciting. d. prevent embarrassing the patient by changing the subject if the patient does not respond. b. ask simple questions that the patient can answer with yes or no. GOOD ONE A patient has a stroke affecting the right hemisphere of the brain. Based on knowledge of the effects of right brain damage, the nurse establishes a nursing diagnosis of a. impaired physical mobility related to right hemiplegia. b. risk for injury related to denial of deficits and impulsiveness. c. impaired verbal communication related to speech-language deficits. d. ineffective coping related to depression and distress about disability. b. risk for injury related to denial of deficits and impulsiveness. ACUTE PHASE VS REHABILITATION PHASE When caring for a patient with left-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care during the acute period of the stroke? a. Apply an eye patch to the left eye. b. Approach the patient from the left side. c. Place objects needed for activities of daily living on the patients right side. d. Reassure the patient that the visual deficit will resolve as the stroke progresses. c. Place objects needed for activities of daily living on the patients right side. The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to impaired self-feeding ability for a patient with right-sided hemiplegia. Which intervention should be included in the plan of care? a. Provide a wide variety of food choices. b. Provide oral care before and after meals. c. Assist the patient to eat with the left hand. d. Teach the patient the chin-tuck technique. c. Assist the patient to eat with the left hand. A patient who has had a stroke has a new order to attempt oral feedings. The nurse should assess the gag reflex and then a. order a varied pureed diet. b. assess the patients appetite. c. assist the patient into a chair. d. offer the patient a sip of juice. c. assist the patient into a chair. A patient who has right-sided weakness after a stroke is attempting to use the left hand for feeding and other activities. The patients wife insists on feeding and dressing him, telling the nurse, I just dont like to see him struggle. Which nursing diagnosis is most appropriate for the patient? a. Situational low self-esteem related to increasing dependence on others b. Interrupted family processes related to effects of illness of a family member c. Disabled family coping related to inadequate understanding by patients spouse d. Impaired nutrition: less than body requirements related to hemiplegia and aphasia c. Disabled family coping related to inadequate understanding by patients spouse Several weeks after a stroke, a patient has urinary incontinence resulting from an impaired awareness of bladder fullness. For an effective bladder training program, which nursing intervention will be best to include in the plan of care? a. Limit fluid intake to 1200 mL daily to reduce urine volume. b. Assist the patient onto the bedside commode every 2 hours. c. Perform intermittent catheterization after each voiding to check for residual urine. d. Use an external condom catheter to protect the skin and prevent embarrassment. b. Assist the patient onto the bedside commode every 2 hours. A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering the medications, the patient says, I dont need the aspirin today. I dont have any aches or pains. Which action should the nurse take? a. Document that the aspirin was refused by the patient. b. Tell the patient that the aspirin is used to prevent aches. c. Explain that the aspirin is ordered to decrease stroke risk. d. Call the health care provider to clarify the medication order. c. Explain that the aspirin is ordered to decrease stroke risk. A patient is admitted to the hospital with dysphasia and right-sided weakness that resolves in a few hours. The nurse will anticipate teaching the patient about a. alteplase (tPA). b. aspirin (Ecotrin). c. warfarin (Coumadin). d. nimodipine (Nimotop). b. aspirin (Ecotrin). BP IS MOST IMPORTANT FACTOR The nurse obtains all of the following information about a 65-year-old patient in the clinic. When developing a plan to decrease stroke risk, which risk factor is most important for the nurse to address? a. The patient has a daily glass of wine to relax. b. The patient is 25 pounds above the ideal weight. c. The patient works at a desk and relaxes by watching television. d. The patients blood pressure (BP) is usually about 180/90 mm Hg. d. The patients blood pressure (BP) is usually about 180/90 mm Hg. A patient with sudden-onset right-sided weakness has a CT scan and is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? a. The patients speech is difficult to understand. b. The patients blood pressure is 144/90 mm Hg. c. The patient takes a diuretic because of a history of hypertension. d. The patient has atrial fibrillation and takes warfarin (Coumadin). d. The patient has atrial fibrillation and takes warfarin (Coumadin). A-fib indicates possible embolic stroke "CT scan is needed before administration of tissueplasminogen activator" A patient with right-sided weakness that started 90 minutes earlier is admitted to the emergency department and all these diagnostic tests are ordered. Which test should be done first? a. Electrocardiogram (ECG) b. Complete blood count (CBC) c. Chest radiograph (Chest x-ray) d. Non-contrast computed tomography (CT) scan d. Non-contrast computed tomography (CT) scan A patient with a stroke has progressive development of neurologic deficits with increasing weakness and decreased level of consciousness (LOC). Which nursing diagnosis has the highest priority for the patient? a. Impaired physical mobility related to weakness b. Disturbed sensory perception related to brain injury c. Risk for impaired skin integrity related to immobility d. Risk for aspiration related to inability to protect airway d. Risk for aspiration related to inability to protect airway A patient who has had a subarachnoid hemorrhage is being cared for in the intensive care unit. Which information about the patient is most important to communicate to the health care provider? a. The patient's blood pressure is 90/50 mm Hg. b. The patient complains about having a stiff neck. c. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs). d. The patient complains of an ongoing severe headache. a. The patient's blood pressure is 90/50 mm Hg. After receiving change-of-shift report on the following four patients, which patient should the nurse see first? a. A patient with right-sided weakness who has an infusion of tPA prescribed b. A patient who has atrial fibrillation and a new order for warfarin (Coumadin) c. A patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due d. A patient with a subarachnoid hemorrhage 2 days ago who has nimodipine (Nimotop) scheduled a. A patient with right-sided weakness who has an infusion of tPA prescribed The nurse is caring for a patient with carotid artery narrowing who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse? a. The pulse rate is 104 beats/min. b. The patient has difficulty talking. c. The blood pressure is 142/88 mm Hg. d. There are fine crackles at the lung bases. b. The patient has difficulty talking. A patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? a. Check the respiratory rate. b. Monitor the blood pressure. c. Send the patient for a CT scan. d. Obtain the Glasgow Coma Scale score. a. Check the respiratory rate. A 58-year-old patient who began experiencing right-sided arm and leg weakness is admitted to the emergency department. Which action will the nurse implement first? a. Obtain CT scan without contrast. b. Infuse tissue plasminogen activator (tPA). c. Administer oxygen to keep O2 saturation >95%. d. Use National Institute of Health Stroke Scale to assess patient. c. Administer oxygen to keep O2 saturation >95%. What is a priority problem immediately following a stroke?Brain edema is the swelling of the brain after a stroke. The swelling is caused by a build-up of fluid and pressure inside the skull that can affect the flow of oxygen and blood to the brain. Brain edema is a life-threatening condition that requires immediate treatment.
Which clinical manifestation is associated with a stroke on the right side of the brain?The effects of a right hemisphere stroke may include: Left-sided weakness or paralysis and sensory impairment. Denial of paralysis or impairment and reduced insight into the problems created by the stroke (this is called "left neglect") Visual problems, including an inability to see the left visual field of each eye.
What is the priority intervention in the emergency department for the patient with a stroke?Patients with suspected acute stroke should have a rapid initial evaluation for airway, breathing and circulation [Evidence Level A]. A neurological examination should be conducted to determine focal neurological deficits and assess stroke severity [Evidence Level A].
Which artery has a defect that is related to the cause of aphasia in a patient with a stroke?In most patients the cause of wernicke aphasia is an embolic stroke that afects the inferior division of the middle cerebral artery, whuch supplies the temporal cortex.
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