Stroke
A 80 year old patient is admitted to the ED with symptoms of suspected stroke. Which of the following actions should the nurse perform first?
1. obtain a detailed medical history
2. administer 325 mg aspirin
3. assess the patient's airway, breathing, and circulation
4. prepare the patient for an EKG
What is 3: Assess the patient's airway, breathing, and circulation
rationale: airway, breathing, and circulation (ABCs) are the primary concerns for suspected stroke. rapid assessment and stabilization are essential before further testing
A nurse is caring for a patient following a stroke who is at risk for increased intracranial pressure (ICP). Which of the following interventions should the nurse implement to help prevent increased ICP?
1. elevate HOB to 30 degrees
2. encourage the patient to cough and deep breathe frequently
3. limit fluid intake to 500ml/day
4. Position the patient supine with the head flat
what is: elevate HOB to 30 degrees
rationale: keeping the HOB elevated promotes venous drainage which can help prevent increased intracranial pressure. excessive coughing can increase ICP and should be avoided
A patient with a history of atrial fibrillation is at increased risk for an embolic stroke. Which medication would the nurse expect to administer to reduce this risk?
1. aspirin
2. heparin
3. warfarin
4. mannitol
What is: warfarin
rationale: patients with a.fib often require anticoagulation therapy, such as warfarin, to prevent the formation of emboli that could lead to an ischemic stroke
The nurse is educating a patient who experienced a transient ischemic attack (TIA) about lifestyle modifications to reduce the risk of stroke. Which lifestyle change is most important?
1. engaging in exercise several times a week
2. reducing sodium intake
3. stop smoking
4. limiting alcohol to 1-2 drinks per day
What is: Stop smoking
A nurse is preparing to discharge a patient who had a stroke. Which intervention should be included in the discharge plan to prevent complications at home?
1. schedule a follow-up CT scan in one week
2. Educate the patient on the use of a walker for mobility
3. Arrage for a home health nurse to monitor vital signs weekly
4. Recommend a high-protein diet to aid recovery
What is: educate the patient on the use of a walker for mobility
rationale: safety is a primary concern post-stroke
A patient with left-sided hemoparesis after a stroke is struggling with activities of daily living. Which intervention would be most benenficial?
1. Encourage the patient to perform ADLs independently without assistance
2. Teach the patient to dress the unaffected side first
3. provide written instructions for each ADL
4. Suggest the use of assistive devices, such as a long-handled spoon or button hook
What is: Suggest the use of assistive devices, such as a long-handled spoon or button hook
rationale: Assistive devices can help patients with hemiparesis be more independent by compensating for their weakness and improving quality of life