s
what are some modifiable risk factors?
age- increase with age
gender - more common in men and more women die
race -African American suffer twice as much
what is the single most important modifiable risk factor?
Hypertension
tell me everything about embolic stroke
occurs when embolus lodge in & occludes a cerebral artery
associated with HEART condition with emboli ( blood pulls) ( leads to clots) ( a fib & CHF)
CAN NOT PCCUR FROM DVT OR CX PE
* change in LOC and severe headache
what baseline lab are you doing for a pt with stroke and why ?
do they diagnose stroke ?
coag panel - pt / ptt clot factor
blood glucose - hypoglycemia can mimic stroke s/s
CMP - electrolytes imbalance can mimic stroke s/s
The client with left-brain damage demonstrates expressive dysphasia. Which nursing intervention is most appropriate when communicating with this client?
A. Ask open-ended questions to encourage detailed verbal responses.
B. Use simple, one-step commands and allow adequate time for a response.
C. Communicate using only written notes and visual aids.
D. Speak loudly and clearly into the client's unaffected ear.
B.
Use simple, one-step commands and allow adequate time for a response.
That's right!
Since the client understands speech but struggles to articulate, using simple phrases and giving time for them to process and respond minimizes anxiety and frustration.
what are the types of stroke?
ischemic stroke - inadequate blood flow to the brain (more common)
hemorrhagic stroke - bleeding into the brain tissue ( more deadly)
Transient ischemic attack TIA - brief interruption of cerebral blood flow. Manifestations of a TIA resolve within 1-24 hours without any permanent deficits. During a TIA, clients might report transient manifestations (visual disturbances, dizziness, slurred speech, a weak extremity), which can be a warning of an impending stroke.
A nurse is creating a safety plan for a client with a right-brain stroke who demonstrates impulsivity. Which action is the most critical to include in the plan?
A. Keeping the bed in the lowest position, utilizing bed alarms, and providing close supervision.
B. Relying on the client's verbal reports of pain and needs.
C. Using only simple, one-word verbal commands to prevent language confusion.
D. Placing all necessary items on the client's left (neglected) side.
A. Keeping the bed in the lowest position, utilizing bed alarms, and providing close supervision.
That's right!
Impulsivity and poor judgment create a high fall risk, requiring passive restraints (bed alarms) and environmental safety modifications (bed low, supervision) to prevent self-harm.
The nurse notes that a client with a recent right-brain stroke is moving through their rehabilitation routine too quickly, attempting to perform tasks beyond their current ability, and has a very short attention span. The most appropriate immediate nursing action is to:
A.
Request a consult for expressive aphasia to address the communication issues.
B.
Encourage the client's rapid performance to motivate them to recover faster.
C.
Break down all tasks into small, distinct steps and provide continuous, structured supervision.
D.
Focus all teaching on explaining the medical reasons for the paralysis.
C.
Break down all tasks into small, distinct steps and provide continuous, structured supervision.
That's right!
The short attention span and impulsivity require simplified instructions (broken tasks) and close monitoring (supervision) to ensure safety and task completion.
tell me everything you know about thrombotic
injury to BV --> clot forms ( plaque breaks off --> occlusion)
(atherosclerosis)
most common type
2/3 associated HTN & DM 30 - 50 % preceded by TIA
A client presents with sudden right-sided paralysis and difficulty speaking clearly, though they seem to understand every command given by the nurse. The nurse interprets these findings as characteristic of a stroke in which area?
A. Left cerebral hemisphere
B.
Brainstem
C.
Cerebellum
D.
Right cerebral hemisphere
A. Left cerebral hemisphere
Right answer
The left hemisphere controls the right side of the body (paralysis) and contains the expressive language center (Broca's area), which explains the clear understanding but difficulty speaking (expressive dysphasia).
as a nurse what should you do in an immediate care for stroke ( 1st 10 mins)
alert stroke team
check abc
remove dentures
maintain oxygen
general neurological assessment
iv access with normal saline
Maintain BP
The physician orders a Calcium Channel Blocker for a client with Subarachnoid Hemorrhage (SAH). The nurse should monitor the client closely for the intended therapeutic effect, which is:
A.A decrease in the client's NIH Stroke Scale score.
B.Prevention of uncontrolled seizures.
C.Normalization of the blood clotting factors (PT/INR).
D.Prevention of cerebral vasospasm, which can cause delayed ischemia.
D.
Prevention of cerebral vasospasm, which can cause delayed ischemia.
That's right!
Calcium channel blockers are used in SAH to prevent or minimize cerebral vasospasm, which can lead to delayed cerebral ischemia and worsening neurological status.
A client is rushed to the Emergency Department by their family after they suddenly experienced difficulty speaking and a noticeable loss of balance. On initial assessment, the nurse notes the client has unilateral facial drooping and is unable to maintain an upward position of their left arm when asked. The family reports the symptoms began approximately 60 minutes ago.
Which nursing action is the highest priority to facilitate rapid stroke management?
A. Obtain a detailed 24-hour diet history and current list of prescribed medications.
B. Prepare to administer an antiplatelet agent like aspirin or clopidogrel immediately upon arrival.
C. Ensure the client is placed on nothing-by-mouth (NPO) status and prepare for an immediate non-contrast computed tomography (CT) scan of the head.
D. Position the client in a high-Fowler's position (90∘) to help decrease cerebral edema and intracranial pressure (ICP).
Rationale for C: The signs (Facial drooping, Arm weakness, Slurred speech - FAST) strongly indicate an acute stroke. The priority in stroke care is rapid diagnosis and intervention. The non-contrast CT scan must be completed STAT to determine if the stroke is ischemic (treatable with thrombolytics) or hemorrhagic (for which thrombolytics are contraindicated). NPO status is critical because swallowing difficulties (dysphagia) often accompany a stroke and placing the patient NPO prevents immediate aspiration, which can quickly compromise the airway.
A client presents with unilateral face, arm, and leg weakness, with a noticeable droop in their smile. The nurse quickly applies the NIH Stroke Scale (NIHSS) and determines the client's score is 3. How should the nurse interpret this finding?
A.
The client is experiencing a moderate to severe stroke, requiring immediate mechanical thrombectomy.
B. The client's symptoms are minor, suggesting a small stroke with a favorable initial outcome.
C. the score is inconclusive and must be re-administered hourly.
D. The client has a severe stroke and should be prepared for surgical management.
B. The client's symptoms are minor, suggesting a small stroke with a favorable initial outcome.
That's right!
An NIHSS score of 1−4 is classified as a minor stroke, meaning the deficits are present but mild.
A client is brought to the Emergency Department with an acute ischemic stroke that started 5 hours ago. Based on the documented time of symptom onset, which action regarding intravenous tPA is appropriate?
A. The decision to give tPA must be made by the Neurologist only, regardless of the time frame.
B. The client remains eligible for tPA, but the dosage must be reduced by half.
C. The client is no longer eligible for tPA and will be treated with supportive measures and aspirin.
D. tPA can be given, but a STAT CT scan must be repeated after administration.
C.
The client is no longer eligible for tPA and will be treated with supportive measures and aspirin.
That's right!
Intravenous tPA must be initiated within 4.5 hours of symptom onset; administering it after this window increases the risk of symptomatic intracerebral hemorrhage without therapeutic benefit.
A client with an acute ischemic stroke is eligible for a surgical procedure to retrieve the clot. The nurse should prepare the client for which procedure?
A.
Aneurysm clipping or coiling
B.
Carotid endarterectomy (CEA)
C.
Mechanical Embolus Removal in Cerebral Ischemia (MERCI) retrieval
D.
External ventricular drain (EVD) placement
C.
Mechanical Embolus Removal in Cerebral Ischemia (MERCI) retrieval
That's right!
The MERCI retriever uses a corkscrew-like device inserted into the artery to physically pull the clot out, which is a key intervention for acute ischemic stroke.
Which instruction should the nurse teach the UAP to use when assisting a stroke client who has chewing and swallowing difficulty (dysphagia)?
A.Place food on the unaffected side of the mouth and encourage a double swallow.
B.Mix medications with a large amount of water to make them easier to swallow.
C.Have the client tilt their head back while swallowing to help the food go down.
D. Encourage the client to drink thin liquids from a straw to ease swallowing effort.
A.
Place food on the unaffected side of the mouth and encourage a double swallow.
That's right!
Placing food on the unaffected side (where muscle control is intact) and encouraging a double swallow are key techniques to reduce the risk of pocketing and aspiration.
A 72-year-old client arrives to the ED with sudden facial drooping, slurred speech, and right-arm weakness. The spouse reports the patient was “normal” 45 minutes ago. The nurse’s priority action is:
A. Start a peripheral IV with normal saline
B. Prepare the patient for an immediate CT scan without contrast
C. Obtain a full medication history
D. Check the patient’s temperature
Answer: B — Immediate CT scan without contrast
Rationale: Time = brain. CT without contrast must be done immediately to rule out hemorrhage before tPA.
A nurse is assessing a client with Homonymous Hemianopsia following a stroke. This condition requires the nurse to intervene by:
A.Restricting physical activity to prevent eye strain and bleeding.
B.Avoiding using verbal cues or gestures, as this can worsen confusion.
C.Cueing the client to actively scan their environment and placing objects in their unaffected field of vision.
D.Covering one eye with a patch to alleviate double vision.
C.
Cueing the client to actively scan their environment and placing objects in their unaffected field of vision.
That's right!
Homonymous hemianopsia (blindness in half of the visual field) requires the nurse to teach scanning techniques and place objects where the client can see them for safety.
A 68-year-old patient arrives with right-sided paralysis and aphasia. Last known well = 2.5 hours ago.
CT scan shows no hemorrhage.
PT/INR, platelets, and glucose are normal.
BP is 192/106.
Which action is priority BEFORE tPA administration?
A. Administer tPA immediately
B. Lower BP per protocol
C. Give aspirin 325 mg
D. Start IV heparin
✅ Answer: B — Lower BP per protocol
Rationale: BP must be controlled before tPA because extremely elevated BP increases bleeding risk. NO antiplatelets/anticoagulants before or 24 hrs after tPA.
A patient on the med-surg unit suddenly screams, “This is the worst headache of my life!”
They become nauseous and vomit. BP = 205/118.
What should the nurse do FIRST?
A. Perform a FAST assessment
B. Notify the provider immediately
C. Give aspirin
D. Check blood glucose
Answer: B — Notify provider immediately
Rationale: Sudden “worst headache of life” = classic hemorrhagic stroke → emergency. Aspirin is contraindicated.
A patient with a hemorrhagic stroke becomes increasingly drowsy, has unequal pupils, and vomits. What is the nurse’s first priority?
A. Perform passive ROM
B. Recheck blood pressure
C. Notify provider and prepare for rapid deterioration
D. Offer oxygen via nasal cannula
✅ Answer: C — Notify provider immediately
Rationale: These are classic increased ICP signs → life-threatening.
A patient presents with slurred speech and confusion. The nurse checks blood glucose and finds it’s 32 mg/dL. What is the significance?
A. The patient has a hemorrhagic stroke
B. The patient is having a TIA
C. Hypoglycemia can mimic a stroke
D. This confirms ischemic stroke
✅ Answer: C — Hypoglycemia can mimic stroke
Rationale: Blood glucose must be checked because low glucose can appear like stroke symptoms.
The nurse is triaging a client brought to the Emergency Department with sudden, severe headache, confusion, and right-sided facial drooping that began 90 minutes ago. The client has a history of uncontrolled hypertension. Based on the client's presentation, which of the following are immediate nursing priorities? Select all that apply.
1. Perform a full Glasgow Coma Scale (GCS) and vital signs assessment.
2. Place the client on nothing-by-mouth (NPO) status.
3. Obtain an immediate order for an antiplatelet agent (e.g., aspirin) to be given orally.
4. Ask the client's family to provide a complete list of all home and over-the-counter medications.
5. Prepare the client for an immediate non-contrast Computed Tomography (CT) scan of the head
6. Perform a STAT fingerstick blood glucose check.
Prepare the client for an immediate non-contrast Computed Tomography (CT) scan of the head.
Right answer
A STAT non-contrast CT scan is the single most critical diagnostic test to differentiate between ischemic and hemorrhagic stroke, guiding time-sensitive treatment decisions.
Perform a STAT fingerstick blood glucose check.
Right answer
Hypoglycemia can perfectly mimic stroke symptoms (like slurred speech and weakness) and must be ruled out immediately as a reversible cause.
Perform a full Glasgow Coma Scale (GCS) and vital signs assessment.
That's right!
A baseline neurological and vital signs assessment, including GCS, is essential for monitoring neurological status, tracking deterioration, and guiding treatment.
Place the client on nothing-by-mouth (NPO) status.
Right answer
Facial drooping and confusion suggest potential dysphagia (difficulty swallowing), making NPO status a priority to prevent aspiration and protect the airway (A in ABCs).
A 76-year-old patient is recovering from an ischemic stroke on the neuro unit. Earlier, the patient was alert and oriented ×3.
Four hours later, the nurse notes:
The patient is now difficult to arouse
Has new-onset left pupil sluggishness
BP: 188/92
HR: 54
The patient vomited once on the sheets
The gag reflex is weaker than before
What is the nurse’s priority action?
A. Elevate HOB and reassess in 15 minutes
B. Notify the provider immediately — signs of increased ICP
C. Check blood glucose to rule out hypoglycemia
D. Document findings and continue neuro checks per protocol
Correct Answer: B — Notify the provider immediately — signs of increased ICP
Rationale (Very Important):
The patient demonstrates classic increased ICP symptoms, which indicate possible cerebral edema or worsening stroke:
Decreased level of consciousness → earliest sign of ICP
Unilateral sluggish pupil → pressure on cranial nerve III
Cushing’s triad signs:
↑ BP with widening pulse pressure
↓ HR (bradycardia)
Vomiting → neurologic trigger
Worsening gag reflex → airway threat
This is a neurologic emergency requiring immediate provider notification and possible prepping for further imaging or intervention.
Reassessing = delays care
Blood glucose is NOT the priority because the neuro signs are focal
Documenting alone = dangerous