Patho
A sudden disruption of blood flow to the brain that impairs neurological function.
What is a stroke/ CVA.
Survey used to assess severity CVA
What is NIHSS?
the higher the score the more severe the stroke is.
Untreated A-fib increases the likelihood a client can experience...
What is an ischemic stroke
This acronym is used to teach clinical staff and provide patient education to recognize clinical symptoms of a stroke
What is F.A.S.T?
* bonus Please explain the acronym and what it stands for
a class of medication used for stroke prevention
What are anticoagulants?
Cause by a thrombus or emboli that occludes cerebral blood flow
What is an ischemic stroke?
the term for the inability to express one's self and the area most likely affected causing this condition
What is aphasia?
s/s of ischemic stroke
What is numbness or weakness of the face, arm, and or leg that is usually one-sided? What is changes in mental status, difficulty speaking or understanding speech (aphasia).
The ED nurse prepares a client with s/s of CVA immediately for this diagnostic test...
What is a CT scan?
To decrease ICP the neurology nurse would expect to administer this diuretic
What is an osmotic diuretic / Lasix/ Mannitol?
Number one cause of CVAs?
What is chronic hypertension
The student understands there are two forms of hemorrhagic strokes
What are intracerebral and subarachnoid hemorrhage?
Abuse of this illicit drug increases chance of an ischemic stroke
What is cocaine abuse?/ Illicit substances
The nurse understands it is inappropriate lie a patient flat that has increased ICP. The nurse knows to...
What is Elevate the head of the bed to a 30 degree angle?
This medication class is used world wide to prevent vasospasms in post hemorrhagic stroke patients...
Which medication is the gold standard?
1) CCBs
2) Nimotop/ nimodipine
Major fuel source for nervous system
What is glucose?
The nurse expects to hear what subjective data from a patient experiencing a SAH (subarachnoid hemorrhage)
What is a severe headache/ Thunder clap "worst headache of my life"
modifiable risk factors
What is treating hypertension, healthy diet, and smoking cessation?
The nurse notices a patient diagnosed with a hemorrhagic CVA starts to breathe irregularly with notable tachycardia then the patient almost immediately goes bradycardic, these two symptoms are indicative of what? What would the nurse notify the provider of?
1) Cushings Triad
2) Brain herniation with impending brain death
A patient has been prescribed Eliquis after suffering an ischemic CVA... What signs/symptoms would the nurse notify the provider for in regards to an adverse effect of this anticoagulation?
Lowering platelet counts, increased PTT/ INR, petechiae, easy bruising, hematuria, hemoptysis, melena, coffee ground emesis (hematemesis)
After a frustrating class, a female instructor c/o dizziness, headache, and right arm weakness. The school nurse recommends she goes to the Emergency department. Once the instructors arrives the symptoms has resolved. Explain what has happened.
What is a TIA (transient ischemia attack)
How often would you expect to do neuro assessments on a patient who is immediately post op from a craniectomy to relieve cerebral pressure?
What is every 15-30 minutes? Or per unit policy
To ensure adequate cerebral perfusion the nurse would be sure to monitor ____ when taking blood pressure
If a patient suffered a SAH that extravasated into the ventricles, what type of device would you believe they would come out with to monitor ICP?
1 )What is Mean Arterial Pressure?
* >65mmhg or provider preference
2) EVD- extraventricular drain
or
Direct ICP monitor
a perceptor nurse intervenes when a senior nursing student assists a client with right hemiparesis to transfer from bed to chair if the nurse concludes which action is BEST to address the needs of the patient.
a) using a transfer belt by applying it around the waist securely
b) Help to stabilize the patient weakened knee during transfer
* this question was adaptated from Mymastery NCLEX APP.
What is help to stabilize the patient weakened knee during transfer?
*this helps with stability and helps decrease falls risk.
The contraindications for tPA include....
•Severe head trauma within 3 months
•Previous ICH
•Suspected SAH
•Brain or spine surgery within 3 months
•SBP>185, DBP> 110
•Bleeding diathesis
•INR >1.7
•Heparin/ LMWH/factor Xa inhibitor within 48 hours
•Thrombocytopenia
•CT + hemorrhage
•>4.5hrs since last known normal