Neuro
What is "FAST" and what is its purpose?
Face, Arm, Speech, Time (call 911). The sooner the treatment for stroke is started, the better the outcomes for patient-- *think act FAST* for stroke s/s
What is the Administration time window for giving TPA for stroke?
3- 4.5 hours
How quickly do TIA symptoms resolve?
30-60 minutes
At change of shift the nurse reports the patients GCS to be a 13. After your assessment their GCS is 10; is this concerning to you the RN? Why or Why not
Yes! indicative of moderate head injury and the patient is declining.
True or False: All patients are eligible for fibrinolytic therapy
FALSE. look at contraindications and TIME ****
Which of the following would you do to perform a neuro assessment on your patient? (Select all that apply)
A. Ask the patient to squeeze your hands and lift their arms
B. Ask the patient to smile
C. Check patients pupil response
D. Assess the patients respiration rate
A B C for a *neuro* assessment
A client with CVA is prescribed medication to treat the disorder. The client wants to know what other measures may help reduce CVA. Which is an accurate suggestion for the client?
A. increase body weight moderately
B. reduce hypertension & high blood cholesterol
C. Increase intake of red meats & carbohydratesD. increase hydration & the intakes of fluids
B. Reduce hypertension & high blood cholesterol
A client who has experienced an initial transient ischemic attack (TIA) states: “I’m glad it wasn’t anything serious.” Which is the best nursing response to this statement?
A. "I sense you are happy it was not a stroke."
B. "People who experience a TIA will develop a stroke."
C. "TIA symptoms are short lived & resolve in within 24 hours."
D. "TIA is a warning sign. Lets talk about your risks."
D.
After completing the NIH stroke scale on your patient, they received a score of 2. What will ADLs look like for this patient?
Minor Stroke* minimal changes at home; maybe rails for walking, etc. should be able to do most ADLs by themselves etc.
The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority?
A. Maintaining accurate records of intake & output
B. Maintaining a patent airway
C. Inserting an NG tube as prescribed
D. providing appropriate pain control
B. Maintaining a patent airway
Which of the following medications could be prescribed for a patient who recently had a TIA? (Select all that apply)
A. Aspirin
B. Plavix
C. Morphine
D. Nitroglycerin
A & B
Time of symptom onset!
After having a TIA, the nurse provided education to their patient. Which of the following statements indicates further teaching is needed:
A. "If my symptoms come back, ill just wait it out at home because I can have TIAs and still be fine."
B. " I need to set up physical therapy."
C. "I need to schedule an appointment with a speech therapist."
D. All of the above
D. All of the above
Which of the following patients would be contraindicated for receiving fibrinolytic therapy? (Select all that apply)
A. Patient is 78 years old
B. Baseline NIH of 15
C. patient was diagnosed with a hemorrhagic stroke
D. Baseline NIH of 30
C & D
167 mL/ Hour
Which of the following, if left untreated, can lead to an ischemic stroke?
A. Atrial Fibrillation
B. Cerebral aneurysm
C. Arteriovenous malformation (AVM)
D. Ruptured Cerebral arteries
A. A fib
Which of the following are risk factors associated with stroke? (Select all that apply)
A. Cocaine Use
B. Hypertension
C. Atrial Fibrillation
D. Consuming a "DASH" diet
A, B, C
The provider diagnoses the patient as having had an ischemic stroke. The etiology of an ischemic stroke would include which of the following?
A. cariogenic emboli
B. Cerebral AneurysmC. Arteriovenous malformation
D. Intracerebral hemorrhage
A. Cariogenic Emboli
A nurse is providing education to a community group about ischemic strokes. One group member asks if there are ways to reduce the risk for stroke. Which of the following is a risk factor that can be modified?
A. Hypertension
B. Male Gender
C. African Heritage
D. Advanced Age
A. Hypertension
Describe PPE for a contact patient
- Gown & Gloves
When communicating with a client who has sensory (receptive) aphasia, the nurse should:
A. allow time for the client to respond
B. speak loudly & articulate clearly
C. give the client a writing pad.
D. Use short, simple sentences
D. Use short simple sentences
Before giving any form of fibrinolytic, what would we assess? What are some contraindications?
- determine onset of symptoms (3-4.5 hr)
-need consent, 2 IVs, watch for s/s of bleeding, etc.
don't give to: hemorrhagic stroke, baseline NIH 25+
How would you prepare a patient for surgery for a hemorrhagic stroke?
- consent, 2 IV sites, prepare for OR, Lab work*
Your patient has an NIH scale score of 40. What will his current ADL and home life look like?
- severe stroke; change in ADLS drastically, will need total care with everything, etc.
Which of the following are non-modifiable risk factors of CAD:
A. Obesity
B. Age
C. Smoking
D. Gender
E. Stress
B & D (age & gender)