The Nursing Life

Neuro: CVA (Stroke)

  • Regular oral hygiene is an essential intervention for the client who has had a stroke.  Which of the following nursing measures is inappropriate when providing oral hygiene?
    1. Placing the client on the back with a small pillow under the head.
    2. Keeping portable suctioning equipment at the bedside.
    3. Opening the client’s mouth with a padded tongue blade.
    4. Cleaning the client’s mouth and teeth with a toothbrush.
  • A 78 year old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech.  Which nursing intervention is priority?
    1. Prepare to administer recombinant tissue plasminogen activator (rt-PA).
    2. Discuss the precipitating factors that caused the symptoms.
    3. Schedule for A STAT computer tomography (CT) scan of the head.
    4. Notify the speech pathologist for an emergency consult.
  • A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration.  Which is the priority nursing assessment?
    1. Current medications.
    2. Complete physical and history.
    3. Time of onset of current stroke.
    4. Upcoming surgical procedures.
  • During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to control the client’s:
    1. Pulse
    2. Respirations
    3. Blood pressure
    4. Temperature
  • What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke?
    1. Cholesterol level
    2. Pupil size and papillary response
    3. Vowel sounds
    4. Echocardiogram
  • What is the expected outcome of thrombolytic drug therapy?
    1. Increased vascular permeability.
    2. Vasoconstriction.
    3. Dissolved emboli.
    4. Prevention of hemorrhage
  • The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA).  Which medication would the nurse anticipate being ordered for the client on discharge?
    1. An oral anticoagulant medication.
    2. A beta-blocker medication.
    3. An anti-hyperuricemic medication.
    4. A thrombolytic medication.
  • Which client would the nurse identify as being most at risk for experiencing a CVA?
    1. A 55-year-old African American male.
    2. An 84-year-old Japanese female.
    3. A 67-year-old Caucasian male.
    4. A 39-year-old pregnant female.
  • Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke?
    1. A blood glucose level of 480 mg/dl.
    2. A right-sided carotid bruit.
    3. A blood pressure of 220/120 mm Hg.
    4. The presence of bronchogenic carcinoma.
  • The nurse and unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis.  Which action by the UAP requires the nurse to intervene?
    1. The assistant places a gait belt around the client’s waist prior to ambulating.
    2. The assistant places the client on the back with the client’s head to the side.
    3. The assistant places her hand under the client’s right axilla to help him/her move up in bed.
    4. The assistant praises the client for attempting to perform ADL’s independently.

 

  1. 1.  A helpless client should be positioned on the side, not on the back.  This lateral position helps secretions escape from the throat and mouth, minimizing the risk of aspiration.  It may be necessary to suction, so having suction equipment at the bedside is necessary. Padded tongue blades are safe to use.   A toothbrush is appropriate to use.
  2. 3.  A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder.  This would also determine if it is a hemorrhagic or ischemic accident and guide the treatment, because only an ischemic stroke can use rt-PA.  This would make (1) not the priority since if a stroke was determined to be hemorrhagic, rt-PA is contraindicated.  Discuss the precipitating factors for teaching would not be a priority and slurred speech would as indicate interference for teaching.  Referring the client for speech therapy would be an intervention after the CVA emergency treatment is administered according to protocol.
  3. 3.  The time of onset of a stroke to t-PA administration is critical.  Administration within 3 hours has better outcomes.  A complete history is not possible in emergency care.  Upcoming surgical procedures will need to be delay if t-PA is administered.  Current medications are relevant, but onset of current stroke takes priority.
  4. 3.  Controlling the blood pressure is critical because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy.  Blood pressure should be maintained according to physician and is specific to the client’s ischemic tissue needs and risks of bleeding from treatment.  Other vital signs are monitored, but the priority is blood pressure.
  5. 2.  It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves.  Cholesterol level is an assessment to be addressed for long-term healthy lifestyle rehabilitation.  Bowel sounds need to be assessed because an ileus or constipation can develop, but is not a priority in the first 24 hours.  An echocardiogram is not needed for the client with a thrombotic stroke.
  6. 3.  Thrombolytic therapy is use to dissolve emboli and reestablish cerebral perfusion.
  7. 1.  Thrombi form secondary to atrial fibrillation, therefore, an anticoagulant would be anticipated to prevent thrombi formation; and oral (warfarin [Coumadin]) at discharge verses intravenous.  Beta blockers slow the heart rate and lower the blood pressure.  Anti-hyperuricemic medication is given to clients with gout.  Thrombolytic medication might have been given at initial presentation but would not be a drug prescribed at discharge.
  8. 1.  Africana Americans have twice the rate of CVA’s as Caucasians; males are more likely to have strokes than females except in advanced years.  Oriental’s have a lower risk, possibly due to their high omega-3 fatty acids.  Pregnancy is a minimal risk factor for CVA.
  9. 3. Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a rupture blood vessel in the cranium.  A bruit in the carotid artery would predispose a client to an embolic or ischemic stroke.  High blood glucose levels could predispose a patient to ischemic stroke, but not hemorrhagic.  Cancer is not a precursor to stroke.
  10. 3.  This action is inappropriate and would require intervention by the nurse because pulling on a flaccid shoulder joint could cause shoulder dislocation; as always use a lift sheet for the client and nurse safety.  All the other actions are appropriate.

 

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