Red Flags
Your patient is admitted for stroke-like symptoms. His heart rhythm was NSR this morning, but now he is showing this dysrhythmia that puts the patient at a 5 times higher risk for having an embolic stroke
Atrial Fibrillation
A patient with a facial droop and slurred speech needs to be watched closely for this complication.
Dysphagia or Aspiration Pneumonia
These are the 2 questions the nurse asks the patient to assess for LOC – understanding
Age and Month
This lobe of the brain primarily is responsible for executive function and judgement.
Frontal lobe or prefrontal cortex
Pupillary changes or gaze deviation are clinical signs that this part of the brain is affected
Brainstem
Three weeks after a stroke a patient is home but is not engaging in the usual activities she used to enjoy. This patient is likely experiencing this condition.
Post-stroke depression
A patient has prior deficits from a CVA 1 year ago. The nurse performs a NIHSS and knows prior deficits are scored or not scored.
You Just Called a Stroke Alert. This time-based clinical data point is important to determine whether the patient is eligible for TNKase.
Last Known Well (LKW)
This significant clinical sign could indicate a patient with an acute CVA is developing increased cerebral edema.
Decreased LOC
A patient has a Subarachnoid Hemorrhage (SAH) from a ruptured aneurysm 3 days ago. He has had a stable neuro exam up till now, but suddenly develops a right-side facial droop and severe right-side weakness. He is possibly developing this complication of SAH.
Delayed Cerebral Ischemia (DCI) or Vasospasm
The nurse is performing a NIHSS on a patient with right arm weakness from a left MCA CVA. If the arm weakness prevents him from performing a finger to nose test, this is a deficit that should be scored. True or False
False
You Just Called a Stroke Alert. In addition to vital signs, which POC test should be obtained.
Blood Glucose
The report from the prior nurse said, “She was a little confused last night.” Your assessment reveals the patient is having trouble naming objects and says yes to every question. This patient is not confused; she has this neuro deficit
Aphasia
A patient is admitted for a large basal ganglia ICH. This is the most important vital sign to monitor in order to prevent further complications.
Blood Pressure
To assess for tactile neglect, the nurse has the patient do this prior to touching both his arms.
Close his or her eyes
The primary visual processing center of the brain is located in this lobe.
Occipital
A patient with a large territory infarct suddenly develops a severe headache. The nurse recognizes this complication may have occurred.
Hemorrhagic conversion of the ischemic stroke
A patient with a temporal lobe infarct is at higher risk for developing this complication.
Seizure
The NIHSS detects most disabling symptoms, but there are a few neurological deficits that are not scored on the NIHSS. Name a few.
Dysphagia, Hand weakness, Ataxia or gait instability
This major artery supplies blood flow to approximately 60-80% of the cerebral hemispheres.
Left and Right Middle Cerebral Artery (MCA)