Stroke Assessment
A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the healthcare provider?
a. The patient's speech is difficult to understand.
b. The patient's blood pressure is 144/90 mm Hg.
c. The patient takes a diuretic because of a history of hypertension.
d. The patient has atrial fibrillation and takes warfarin (Coumadin).
d. The patient has atrial fibrillation and takes warfarin (Coumadin).
D. The use of warfarin probably contributed to intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of Warfarin, especially if the patient is to have surgery to correct the bleeding. A history of hypertension is a risk factor for the patient but has no immediate effect on the patient's care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated.
A patient admitted with a possible stroke has been aphasic for 3 hours and his current blood pressure (BP) is 174/94 mm Hg. Which order by the health care provider should the nurse question?
a. Keep the head of the bed elevated at least 30 degrees.
b. Infuse normal saline intravenously at 75 mL/hr.
c. Administer tissue plasminogen activator (tPA) per protocol.
d. Administer a labetalol (Normodyne) drip to keep BP less than 140/90 mm Hg.
d. Administer Labetalol (Normodyne) drip to keep BP less than 140/90 mm Hg.
D. Because elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if mean arterial pressure (MAP) is >130 mm Hg or systolic pressure is >220 mm Hg. Fluid intake should be 1500 to 2000 mL daily to maintain cerebral blood flow. The head of the bed should be elevated to at least 30 degrees, unless the patient has symptoms of poor tissue perfusion. tPA may be administered if the patient meets the other criteria for tPA use.
What are the national guidelines for door-to-imaging times (DIT) for a patient with a suspected stroke?
a. 60 minutes
b. 30 minutes
c. 45 minutes
d. 25 minutes
d. 25 minutes
Rationale: According to the American heart association patients with suspected stroke should bypass the ED and go straight to CT given that they notify the receiving ED.
(Reznek et al.,2016)
The window for availbilty to administer tPA in ischemic strokes is?
a. 6 hours after onset of symptoms
b. 2 hours after onset of symptoms
c. 3 hours after onset of symptoms
d. patients with ischemic stroke do not qualify
c. 3 hours after onset of symptoms
Rationale:
Ischemic stroke (most common) in patients presenting to the treating facility within 3 hours (4.5 hours in certain, eligible people) after the onset of symptoms
(Jilani & Siddiqui,2023)
A 40-year-old patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan?
a. Apply intermittent pneumatic compression stockings.
b. Assist to dangle on edge of the bed and assess for dizziness.
c. Encourage the patient to cough and deep breathe every 4 hours.
d. Insert an oropharyngeal airway to prevent airway obstruction.
a. Apply intermittent pneumatic compression stockings.
Rationale:
The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thromboembolism (VTE). Activities such as coughing and sitting up that might increase intracranial pressure (ICP) or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate.
The nurse is discharging a patient admitted with a transient ischemic attack(TIA). For which medications might the nurse expect to provide discharge instructions? (Select all that apply.)
Ticlopidine
Clopidogrel
Enoxaparin
Dipyridamole
Enteric-coated aspirin
Tissue plasminogen activator (tPA)
Ticlopidine
Clopidogrel
Dipyridamole
Enteric-coated aspirin
Rationale: Aspirin is the most frequently used antiplatelet agent. Other drugs to prevent clot formation include Clopidogrel, Dipyridamole, Ticlopidine combined Dipyridamole and aspirin, and anticoagulant drugs such as oral Warfarin. Tissue plasminogen activator is fibrinolytic medications used to treat ischemic stroke, not prevent TIAs or strokes.
(Lewis,2022)
A 63-yr-old patient who began experiencing right arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol? (Put a comma and a space between each answer choice [A, B, C, D].)
a. Obtain CT scan without contrast.
b. Infuse tissue plasminogen activator (tPA).
c. Administer oxygen to keep O2 saturation >95%.
d. Use National Institute of Health Stroke Scale to assess patient.
C, A,D, B
(Lewis,2022)
A patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. Health records show a history of several transient ischemic attacks (TIAs). What should the nurse anticipate for this patient?
a. Surgical endarterectomy
b. Transluminal angioplasty
c. Intravenous heparin drip administration
d. Tissue plasminogen activator (tPa) infusion
d. Tissue plasminogen activator (tPa) infusion
(Lewis,2022)
The nurse would expect what assessment finding in a patient admitted with a left-sided stroke?
a. Impulsivity
b. Impaired speech
c. Left-sided neglect
d. Short attention span
b. Impaired speech
Rationale: Manifestations of left-sided brain damage include right hemiplegia, impaired speech/language, impaired right/left discrimination, and slow and cautious performance. Impulsivity. left-sided neglect and short attention span are all manifestations of right-sided brain damage.
(Lewis,2022)
Aspirin is ordered for a patient who is admitted with a possible stroke. Which information obtained during the admission assessment indicates that the nurse should consult with the health care provider before giving the aspirin?
a. The patient has dysphasia.
b. The patient has atrial fibrillation.
c. The patient states, My symptoms started with a terrible headache.
d. The patient has a history of brief episodes of right-sided hemiplegia.
c. The patient states, My symptoms started with a terrible headache.
Rationale: A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack (TIA) are not contraindications to aspirin use, so the nurse cannot administer the aspirin.
A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first?
a. Complete blood count (CBC)
b. Chest radiograph (Chest x-ray)
c. 12-Lead electrocardiogram (ECG)
d. Noncontrast computed tomography (CT) scan
d. Noncontrast computed tomography (CT) scan
D. Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 4.5 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the less brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.
(Lewis, 2022)
After receiving a patient who presents with stroke symptoms the ED nurse questions tPA orders based on what history?
a. had a pacemaker implantation 6 months ago
b. had a Liver biopsy 5 weeks ago
c. had an MVA 36hrs ago
d. had a nosebleed yesterday
c. had an MVA 36hrs ago
Hold tPA
Rationale:
If the patient underwent recent (less than three months ago) intracranial or intraspinal surgery or suffered a serious head trauma
(Jilani & Siddiqui,2023)
The patient with diabetes had a right-sided stroke. Which nursing interventions should the nurse plan to provide for this patient?
a. Safety measures
b. Patience with communication
c. Mobility assistance on the right side
d. Place food in the left side of patient's tray
a. safety measures
Rationale: A patient with a right-sided stroke has spatial-perceptual deficits, tends to minimize problems, has a short attention span, is impulsive, and may have impaired judgment. Safety is the biggest concern for this patient. Hemiplegia occurs on the left side of this patient's body. The patient with la eft-sided stroke has hemiplegia on the right, is more likely to have communication problems, and needs mobility assistance on the right side with food placed on the left side if the patient needs to be fed after a swallowed evaluation has taken place.
(Lewis,2022)
What will the nurse tell the patient who has cerebral atherosclerosis about taking clopidogrel (Plavix)?
a. Monitor and record the blood pressure daily.
b. Call the health care provider if stools are tarry.
c. Clopidogrel will dissolve clots in the cerebral arteries.
d. Clopidogrel will reduce cerebral artery plaque formation.
b. Call the health care provider if stools are tarry.
(Lewis,2022)
What labs are necessary to give tPA?
a. CBC
b. BMP
c. Blood glucose
d. PTT/INR
c. Blood glucose
Rationale: the only lab necessary before administration of tPA is blood glucose and if the patient is on blood thinners PTT/INR. It is imperative that there is no delay in the administration of tPA if it is indicated.
(Hughes et al.,2022)
Pt arrives at ED, the attending reports the patient can have tPA after all criteria are met, the nurse questions this order because:
a. the patient is confused
b. the patient's family is not there for consent
c. the blood pressure is 190/119
d. the blood pressure is 109/70
c. the blood pressure is 190/119
Hold tPA
Rationale: Persistently elevated blood pressure (systolic >185mm Hg or diastolic >110 mm Hg) despite treatment is a contraindication for tPA.
(AHA,2018)