Question 1
Regular
The nurse is caring for a patient who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects. Which of the following actions should the nurse anticipate as treatment for this patient?
Correct!
Incorrect
The correct answer is: C
Rationale
Oral administration of low dose Aspirin therapy. This patient’s transient symptoms suggest a possible transient ischemic attack (TIA), where low-dose aspirin is recommended to reduce the risk of future strokes and manage vascular health.
A: Prophylactic clipping of cerebral aneurysms. This invasive procedure is reserved for patients with confirmed aneurysms, which is not indicated in a case of transient neurological symptoms without structural abnormalities.
B: Heparin via continuous intravenous infusion. This anticoagulant is typically utilized in acute thrombotic events, not for transient symptoms that resolve completely without lasting effects, indicating a lower risk scenario.
D: Therapy with tissue plasminogen activator (tPA). This treatment is intended for acute ischemic stroke cases, necessitating immediate intervention, which does not apply here due to the absence of permanent deficits.
Correct Answer: C
Rationale: Oral administration of low dose Aspirin therapy. This patient’s transient symptoms suggest a possible transient ischemic attack (TIA), where low-dose aspirin is recommended to reduce the risk of future strokes and manage vascular health.
A: Prophylactic clipping of cerebral aneurysms. This invasive procedure is reserved for patients with confirmed aneurysms, which is not indicated in a case of transient neurological symptoms without structural abnormalities.
B: Heparin via continuous intravenous infusion. This anticoagulant is typically utilized in acute thrombotic events, not for transient symptoms that resolve completely without lasting effects, indicating a lower risk scenario.
D: Therapy with tissue plasminogen activator (tPA). This treatment is intended for acute ischemic stroke cases, necessitating immediate intervention, which does not apply here due to the absence of permanent deficits.
Question 2
Regular
The nurse is caring for a patient who has recently experienced a stroke. When reviewing the patients' laboratory report, which of the following results should the nurse report the health care provider?
Correct!
Incorrect
The correct answer is: B
Rationale
B: Platelets 95,000/?┬╝L A platelet count of 95,000 is significantly low, indicating thrombocytopenia. This condition can lead to increased bleeding risk, which is critical to address in stroke management and requires immediate reporting to the healthcare provider.
A: PaCO2 35 mm Hg This value falls within the normal range for carbon dioxide levels, indicating proper respiratory function and not necessitating urgent intervention or reporting.
C: Serum sodium 140 mmol/L Sodium levels are considered normal, indicating that the patient's electrolyte balance is stable and does not require immediate attention from the healthcare provider.
D: Cholesterol 200 mg/dL While this cholesterol level is at the upper limit of normal, it is not critical for immediate reporting and does not pose an acute risk to the patient.
Correct Answer: B
Rationale: B: Platelets 95,000/?┬╝L A platelet count of 95,000 is significantly low, indicating thrombocytopenia. This condition can lead to increased bleeding risk, which is critical to address in stroke management and requires immediate reporting to the healthcare provider.
A: PaCO2 35 mm Hg This value falls within the normal range for carbon dioxide levels, indicating proper respiratory function and not necessitating urgent intervention or reporting.
C: Serum sodium 140 mmol/L Sodium levels are considered normal, indicating that the patient's electrolyte balance is stable and does not require immediate attention from the healthcare provider.
D: Cholesterol 200 mg/dL While this cholesterol level is at the upper limit of normal, it is not critical for immediate reporting and does not pose an acute risk to the patient.
Question 3
Regular
The nurse receives a verbal report that a patient has an occlusion of the left posterior cerebral artery. Which of the following findings should the nurse anticipate?
Correct!
Incorrect
The correct answer is: C
Rationale
C: Visual deficits. Occlusion of the left posterior cerebral artery typically leads to visual impairments, such as hemianopia or visual field loss, due to its role in processing visual information from the visual cortex.
A: Dysphagia. This symptom is primarily associated with brainstem or lower cranial nerve issues, not specifically linked to posterior cerebral artery occlusion, which affects visual and cognitive functions.
B: Confusion. While cognitive changes can occur, confusion is more indicative of frontal lobe or generalized cerebral dysfunction, rather than the specific deficits associated with posterior cerebral artery occlusion.
D: Poor judgement. This symptom relates more closely to frontal lobe issues, which are not typically affected by occlusion of the posterior cerebral artery, where visual processing is disrupted instead.
Correct Answer: C
Rationale: C: Visual deficits. Occlusion of the left posterior cerebral artery typically leads to visual impairments, such as hemianopia or visual field loss, due to its role in processing visual information from the visual cortex.
A: Dysphagia. This symptom is primarily associated with brainstem or lower cranial nerve issues, not specifically linked to posterior cerebral artery occlusion, which affects visual and cognitive functions.
B: Confusion. While cognitive changes can occur, confusion is more indicative of frontal lobe or generalized cerebral dysfunction, rather than the specific deficits associated with posterior cerebral artery occlusion.
D: Poor judgement. This symptom relates more closely to frontal lobe issues, which are not typically affected by occlusion of the posterior cerebral artery, where visual processing is disrupted instead.
Question 4
Regular
The health care provider prescribes clopidogrel for a patient with cerebral atherosclerosis. Which of the following information should the nurse include when teaching the patient about the new medication?
Correct!
Incorrect
The correct answer is: B
Rationale
Call the health care provider if stools are tarry.
This information is crucial as tarry stools may indicate gastrointestinal bleeding, a serious side effect of clopidogrel. Patients must be vigilant and report such symptoms promptly to ensure timely medical intervention and prevent complications related to bleeding disorders.
A: Monitor and record the blood pressure daily. Blood pressure monitoring is not a specific requirement for clopidogrel, as its primary role is to prevent clot formation rather than directly affecting blood pressure.
C: It will dissolve clots in the cerebral arteries. Clopidogrel functions as an antiplatelet agent, preventing further clot formation, rather than actively dissolving existing clots in the arteries.
D: It will reduce cerebral artery plaque formation. Clopidogrel does not reduce plaque; instead, it inhibits platelet aggregation to minimize clot development, which is distinct from plaque reduction in arteries.
Correct Answer: B
Rationale: Call the health care provider if stools are tarry.
This information is crucial as tarry stools may indicate gastrointestinal bleeding, a serious side effect of clopidogrel. Patients must be vigilant and report such symptoms promptly to ensure timely medical intervention and prevent complications related to bleeding disorders.
A: Monitor and record the blood pressure daily. Blood pressure monitoring is not a specific requirement for clopidogrel, as its primary role is to prevent clot formation rather than directly affecting blood pressure.
C: It will dissolve clots in the cerebral arteries. Clopidogrel functions as an antiplatelet agent, preventing further clot formation, rather than actively dissolving existing clots in the arteries.
D: It will reduce cerebral artery plaque formation. Clopidogrel does not reduce plaque; instead, it inhibits platelet aggregation to minimize clot development, which is distinct from plaque reduction in arteries.
Question 5
Regular
The health care provider recommends a carotid endarterectomy for a patient with carotid atherosclerosis and a history of transient ischemic attacks (TIA). The patient asks the nurse to describe the procedure. Which of the following responses by the nurse is appropriate?
Correct!
Incorrect
The correct answer is: A
Rationale
The carotid endarterectomy involves surgical removal of plaque from an artery in the neck. This procedure targets the carotid arteries, addressing the buildup of atherosclerotic plaque, which can lead to strokes, particularly in patients with a history of TIAs. By removing this plaque, blood flow is restored, significantly reducing the risk of further neurological events.
B: The diseased portion of the artery in the brain is removed and replaced with a synthetic graft. This describes a different surgical procedure, specifically a bypass or grafting technique, rather than the plaque removal characteristic of a carotid endarterectomy.
C: A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed. This describes a thrombectomy procedure, which focuses on clot retrieval rather than the removal of plaque from the carotid artery.
D: A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque. This describes balloon angioplasty, a method for widening arteries, rather than the surgical intervention of carotid endarterectomy that specifically removes plaque.
Correct Answer: A
Rationale: The carotid endarterectomy involves surgical removal of plaque from an artery in the neck. This procedure targets the carotid arteries, addressing the buildup of atherosclerotic plaque, which can lead to strokes, particularly in patients with a history of TIAs. By removing this plaque, blood flow is restored, significantly reducing the risk of further neurological events.
B: The diseased portion of the artery in the brain is removed and replaced with a synthetic graft. This describes a different surgical procedure, specifically a bypass or grafting technique, rather than the plaque removal characteristic of a carotid endarterectomy.
C: A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed. This describes a thrombectomy procedure, which focuses on clot retrieval rather than the removal of plaque from the carotid artery.
D: A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque. This describes balloon angioplasty, a method for widening arteries, rather than the surgical intervention of carotid endarterectomy that specifically removes plaque.
Question 6
Regular
The nurse is assessing a patient with a possible stroke and finds that the patient's aphasia started 3.5 hours previously and the blood pressure is 170/92 mm Hg. Which of these prescriptions by the health care provider should the nurse question?
Correct!
Incorrect
The correct answer is: D
Rationale
Administer tissue plasminogen activator (tPA) per protocol. tPA is a crucial treatment for ischemic stroke and can only be administered within a specific time frame after symptom onset, which in this case is appropriate given the 3.5-hour window.
A: Infuse normal saline at 75 mL/hour. Administering normal saline helps maintain hydration and can assist in ensuring adequate blood flow without compromising blood pressure management.
B: Keep head of bed elevated at least 30 degrees. Elevating the head of the bed can enhance cerebral perfusion and reduce intracranial pressure, which is beneficial for stroke patients.
C: Administer tissue plasminogen activator (tPA) per protocol. This treatment is essential for eligible patients experiencing an ischemic stroke; thus, questioning its administration would be inappropriate.
Correct Answer: D
Rationale: Administer tissue plasminogen activator (tPA) per protocol. tPA is a crucial treatment for ischemic stroke and can only be administered within a specific time frame after symptom onset, which in this case is appropriate given the 3.5-hour window.
A: Infuse normal saline at 75 mL/hour. Administering normal saline helps maintain hydration and can assist in ensuring adequate blood flow without compromising blood pressure management.
B: Keep head of bed elevated at least 30 degrees. Elevating the head of the bed can enhance cerebral perfusion and reduce intracranial pressure, which is beneficial for stroke patients.
C: Administer tissue plasminogen activator (tPA) per protocol. This treatment is essential for eligible patients experiencing an ischemic stroke; thus, questioning its administration would be inappropriate.
Question 7
Regular
A patient with a history of several transient ischemic attacks (TIAs) arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. Which of the following procedures should the nurse anticipate?
Correct!
Incorrect
The correct answer is: D
Rationale
D: Tissue plasminogen activator (tPA) infusion. This procedure is crucial for treating acute ischemic strokes, especially in patients exhibiting symptoms like hemiparesis and dysarthria within a 3-hour window from onset.
A: Surgical endarterectomy. This procedure is typically performed for chronic carotid artery occlusions rather than acute ischemic events and doesn't address immediate symptoms effectively.
B: Transluminal angioplasty. This intervention is generally aimed at managing chronic vascular blockages and is not suitable for acute ischemic stroke management in this scenario.
C: Intravenous heparin administration. While anticoagulation can be beneficial in certain contexts, it is not the first line of treatment for acute ischemic strokes like TIAs.
Correct Answer: D
Rationale: D: Tissue plasminogen activator (tPA) infusion. This procedure is crucial for treating acute ischemic strokes, especially in patients exhibiting symptoms like hemiparesis and dysarthria within a 3-hour window from onset.
A: Surgical endarterectomy. This procedure is typically performed for chronic carotid artery occlusions rather than acute ischemic events and doesn't address immediate symptoms effectively.
B: Transluminal angioplasty. This intervention is generally aimed at managing chronic vascular blockages and is not suitable for acute ischemic stroke management in this scenario.
C: Intravenous heparin administration. While anticoagulation can be beneficial in certain contexts, it is not the first line of treatment for acute ischemic strokes like TIAs.
Question 8
Regular
The nurse identifies the nursing diagnosis of impaired verbal communication for a patient with expressive aphasia. Which of the following actions should the nurse implement to help the patient communicate?
Correct!
Incorrect
The correct answer is: B
Rationale
B: Asking simple questions that the patient can answer with 'yes' or 'no' facilitates communication by allowing them to respond without the pressure of formulating complex sentences, which is challenging with expressive aphasia. This method supports their ability to engage while minimizing frustration.
A: Having the patient practice facial and tongue exercises focuses on physical capabilities rather than addressing the communication barriers caused by expressive aphasia, thus not directly aiding verbal expression.
C: Developing a list of words for reading and recitation may enhance vocabulary but does not effectively address the immediate communication needs in a conversational context, limiting practical application.
D: Changing the subject to prevent embarrassment dismisses the patient’s attempts to communicate, potentially exacerbating feelings of isolation and preventing the development of effective communication strategies.
Correct Answer: B
Rationale: B: Asking simple questions that the patient can answer with 'yes' or 'no' facilitates communication by allowing them to respond without the pressure of formulating complex sentences, which is challenging with expressive aphasia. This method supports their ability to engage while minimizing frustration.
A: Having the patient practice facial and tongue exercises focuses on physical capabilities rather than addressing the communication barriers caused by expressive aphasia, thus not directly aiding verbal expression.
C: Developing a list of words for reading and recitation may enhance vocabulary but does not effectively address the immediate communication needs in a conversational context, limiting practical application.
D: Changing the subject to prevent embarrassment dismisses the patient’s attempts to communicate, potentially exacerbating feelings of isolation and preventing the development of effective communication strategies.
Question 9
Regular
The nurse is caring for a patient who had a stroke affecting the right hemisphere of the brain. Which of the following nursing diagnoses is appropriate based on knowledge of the effects of right brain damage?
Correct!
Incorrect
The correct answer is: B
Rationale
Risk for injury as evidenced by alteration in cognitive functioning. Damage to the right hemisphere of the brain often leads to neglect and impaired judgment, significantly increasing the patient's risk for injury due to cognitive deficits.
A: Impaired physical mobility related to decrease in muscle control (right hemiplegia) focuses on mobility issues usually linked to left hemisphere damage, which typically affects motor control on the opposite side.
C: Impaired verbal communication related to environmental barrier (impaired speech) pertains more to left hemisphere damage, which primarily affects language skills, making it unsuitable for right hemisphere stroke patients.
D: Ineffective coping related to insufficient sense of control (depression and distress about disability) addresses emotional responses but does not reflect the primary cognitive alterations arising from right hemisphere damage.
Correct Answer: B
Rationale: Risk for injury as evidenced by alteration in cognitive functioning. Damage to the right hemisphere of the brain often leads to neglect and impaired judgment, significantly increasing the patient's risk for injury due to cognitive deficits.
A: Impaired physical mobility related to decrease in muscle control (right hemiplegia) focuses on mobility issues usually linked to left hemisphere damage, which typically affects motor control on the opposite side.
C: Impaired verbal communication related to environmental barrier (impaired speech) pertains more to left hemisphere damage, which primarily affects language skills, making it unsuitable for right hemisphere stroke patients.
D: Ineffective coping related to insufficient sense of control (depression and distress about disability) addresses emotional responses but does not reflect the primary cognitive alterations arising from right hemisphere damage.
Question 10
Regular
The nurse is admitting a patient with left-sided homonymous hemianopsia resulting from a stroke. Which of the following interventions should the nurse include in the plan of care during the acute period of the stroke?
Correct!
Incorrect
The correct answer is: C
Rationale
C: Place objects needed for activities of daily living on the patient's right side. This intervention accommodates the patient’s visual deficit by ensuring necessary items are within their remaining visual field, promoting independence and safety during recovery.
A: Apply an eye patch to the left eye. Covering the left eye does not address the right-sided deficit and may further complicate the patient's ability to navigate their environment.
B: Approach the patient from the left side. Approaching from the left side could startle the patient, as they have limited awareness of that visual field, potentially causing anxiety or disorientation.
D: Reassure the patient that the visual deficit will resolve as the stroke progresses. Offering false hope about recovery can lead to unrealistic expectations, thereby hindering the patient's adjustment and rehabilitation process.
Correct Answer: C
Rationale: C: Place objects needed for activities of daily living on the patient's right side. This intervention accommodates the patient’s visual deficit by ensuring necessary items are within their remaining visual field, promoting independence and safety during recovery.
A: Apply an eye patch to the left eye. Covering the left eye does not address the right-sided deficit and may further complicate the patient's ability to navigate their environment.
B: Approach the patient from the left side. Approaching from the left side could startle the patient, as they have limited awareness of that visual field, potentially causing anxiety or disorientation.
D: Reassure the patient that the visual deficit will resolve as the stroke progresses. Offering false hope about recovery can lead to unrealistic expectations, thereby hindering the patient's adjustment and rehabilitation process.
Question 11
Regular
The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to insufficient dietary intake (secondary to impaired self-feeding ability) for a patient with right-sided hemiplegia. Which of the following interventions should be included in the plan of care?
Correct!
Incorrect
The correct answer is: C
Rationale
Assist the patient to eat with the left hand. This intervention directly addresses the impaired self-feeding ability due to right-sided hemiplegia, enabling the patient to consume sufficient nutrition while promoting independence.
A: Provide a wide variety of food choices. While variety can enhance appetite, it does not directly assist with the physical challenges the patient faces in self-feeding.
B: Provide oral care before and after meals. Although oral hygiene is important, this intervention does not contribute to addressing the patient's immediate nutritional intake or self-feeding difficulties.
D: Teach the patient the 'chin-tuck' technique. This technique is useful for swallowing safety but does not facilitate the actual act of eating for someone with impaired self-feeding capability.
Correct Answer: C
Rationale: Assist the patient to eat with the left hand. This intervention directly addresses the impaired self-feeding ability due to right-sided hemiplegia, enabling the patient to consume sufficient nutrition while promoting independence.
A: Provide a wide variety of food choices. While variety can enhance appetite, it does not directly assist with the physical challenges the patient faces in self-feeding.
B: Provide oral care before and after meals. Although oral hygiene is important, this intervention does not contribute to addressing the patient's immediate nutritional intake or self-feeding difficulties.
D: Teach the patient the 'chin-tuck' technique. This technique is useful for swallowing safety but does not facilitate the actual act of eating for someone with impaired self-feeding capability.
Question 12
Regular
The nurse is caring for a patient who had a stroke resulting from a ruptured aneurysm and subarachnoid hemorrhage. Which of the following interventions should be included in the care plan?
Correct!
Incorrect
The correct answer is: A
Rationale
Applying compression gradient stockings promotes venous return, reducing the risk of deep vein thrombosis, which is critical for a stroke patient with potential immobility and circulatory issues following a ruptured aneurysm.
B: Assisting to dangle on edge of bed and assess for dizziness could lead to falls or complications, especially in a post-stroke patient who may have balance issues.
C: Encouraging patient to cough and deep breathe every 4 hours may not address the specific circulatory risk factors associated with a stroke from an aneurysm rupture effectively.
D: Inserting an oropharyngeal airway to prevent airway obstruction isn’t a standard intervention for this patient scenario, as airway management depends on consciousness and protective reflexes post-stroke.
Correct Answer: A
Rationale: Applying compression gradient stockings promotes venous return, reducing the risk of deep vein thrombosis, which is critical for a stroke patient with potential immobility and circulatory issues following a ruptured aneurysm.
B: Assisting to dangle on edge of bed and assess for dizziness could lead to falls or complications, especially in a post-stroke patient who may have balance issues.
C: Encouraging patient to cough and deep breathe every 4 hours may not address the specific circulatory risk factors associated with a stroke from an aneurysm rupture effectively.
D: Inserting an oropharyngeal airway to prevent airway obstruction isn’t a standard intervention for this patient scenario, as airway management depends on consciousness and protective reflexes post-stroke.
Question 13
Regular
The nurse is caring for a patient who has had a stroke and has a new prescription to attempt oral feedings. After assessing the patient's gag reflex, which of the following actions should the nurse do next?
Correct!
Incorrect
The correct answer is: C
Rationale
C: Assist the patient into a chair. Positioning the patient upright in a chair is essential for safe oral feeding, as it helps prevent aspiration and promotes effective swallowing after a stroke.
A: Order a varied puréed diet. While a puréed diet may be necessary, it is premature to order this without first ensuring the patient's safe positioning for eating.
B: Assess the patient's appetite. Understanding appetite is important, but it is secondary to ensuring the patient is correctly positioned for feeding to mitigate risks during eating.
D: Offer the patient a sip of juice. Directly offering juice without ensuring proper positioning could lead to choking or aspiration, which is unsafe for a stroke patient with swallowing difficulties.
Correct Answer: C
Rationale: C: Assist the patient into a chair. Positioning the patient upright in a chair is essential for safe oral feeding, as it helps prevent aspiration and promotes effective swallowing after a stroke.
A: Order a varied puréed diet. While a puréed diet may be necessary, it is premature to order this without first ensuring the patient's safe positioning for eating.
B: Assess the patient's appetite. Understanding appetite is important, but it is secondary to ensuring the patient is correctly positioned for feeding to mitigate risks during eating.
D: Offer the patient a sip of juice. Directly offering juice without ensuring proper positioning could lead to choking or aspiration, which is unsafe for a stroke patient with swallowing difficulties.
Question 14
Regular
The nurse is caring for a patient who has right-sided weakness after a stroke and is attempting to use the left hand for feeding and other activities. The patient's partner insists on feeding and dressing him, telling the nurse, 'I just don't like to see him struggle.' Which of the following nursing diagnoses is most appropriate for the patient?
Correct!
Incorrect
The correct answer is: C
Rationale
C: Disabled family coping related to differing coping styles between support person and patient. This diagnosis reflects the conflict between the patient's desire for independence and the partner's inclination to control the caregiving process, which can hinder recovery and adaptation.
A: Situational low self-esteem related to pattern of helplessness. This option overlooks the patient's active attempts to engage in self-care, indicating a desire for autonomy rather than a consistent sense of helplessness.
B: Interrupted family processes related to shift in family roles (effects of illness of a family member). While family roles are affected, this diagnosis does not address the specific dynamic between the patient’s independence and the partner’s controlling behavior.
D: Impaired nutrition: less than body requirements related to insufficient dietary intake (hemiplegia and aphasia). This choice does not consider the patient’s efforts to feed himself, focusing instead on nutritional intake without addressing the emotional and relational dynamics at play.
Correct Answer: C
Rationale: C: Disabled family coping related to differing coping styles between support person and patient. This diagnosis reflects the conflict between the patient's desire for independence and the partner's inclination to control the caregiving process, which can hinder recovery and adaptation.
A: Situational low self-esteem related to pattern of helplessness. This option overlooks the patient's active attempts to engage in self-care, indicating a desire for autonomy rather than a consistent sense of helplessness.
B: Interrupted family processes related to shift in family roles (effects of illness of a family member). While family roles are affected, this diagnosis does not address the specific dynamic between the patient’s independence and the partner’s controlling behavior.
D: Impaired nutrition: less than body requirements related to insufficient dietary intake (hemiplegia and aphasia). This choice does not consider the patient’s efforts to feed himself, focusing instead on nutritional intake without addressing the emotional and relational dynamics at play.
Question 15
Regular
Several weeks after a stroke, a patient has urinary incontinence resulting from an impaired awareness of bladder fullness. For an effective bladder training program, which of the following nursing interventions will be best to include in the plan of care?
Correct!
Incorrect
The correct answer is: B
Rationale
Assist the patient onto the bedside commode every 2 hours. Regularly scheduled toileting helps the patient develop a routine, enhancing awareness of bladder fullness and promoting better control over urinary function post-stroke.
A: Limit fluid intake to 1200 mL daily to reduce urine volume. This approach can lead to dehydration, negatively impacting overall health and potentially worsening urinary incontinence.
C: Perform intermittent catheterization after each voiding to check for residual urine. This method is invasive and may not foster the patient’s awareness of bladder fullness, which is crucial for training.
D: Use an external 'condom' catheter to protect the skin and prevent embarrassment. While this may protect the skin, it does not address the need for bladder training and awareness improvement.
Correct Answer: B
Rationale: Assist the patient onto the bedside commode every 2 hours. Regularly scheduled toileting helps the patient develop a routine, enhancing awareness of bladder fullness and promoting better control over urinary function post-stroke.
A: Limit fluid intake to 1200 mL daily to reduce urine volume. This approach can lead to dehydration, negatively impacting overall health and potentially worsening urinary incontinence.
C: Perform intermittent catheterization after each voiding to check for residual urine. This method is invasive and may not foster the patient’s awareness of bladder fullness, which is crucial for training.
D: Use an external 'condom' catheter to protect the skin and prevent embarrassment. While this may protect the skin, it does not address the need for bladder training and awareness improvement.
Question 16
Regular
A patient who has a history of a transient ischemic attack (TIA) has an order for Aspirin 160 mg daily. When the nurse is administering the medications, the patient says, 'I don't need the Aspirin today. I don't have any aches or pains.' Which of the following actions should the nurse take?
Correct!
Incorrect
The correct answer is: C
Rationale
Explain that the Aspirin is ordered to decrease stroke risk.
Aspirin is prescribed post-TIA to reduce the likelihood of stroke by preventing blood clots. The patient’s understanding of the medication’s purpose is crucial for adherence and overall health management, especially after a transient ischemic event.
A: Document that the Aspirin was refused by the patient. This action does not address the patient’s misunderstanding or educate them about the importance of the medication for stroke prevention.
B: Tell the patient that the Aspirin is used to prevent aches. Misleading the patient by associating Aspirin with pain relief undermines its critical role in preventing serious vascular events like strokes.
D: Call the health care provider to clarify the medication order. Clarifying the order is unnecessary when the focus should be on educating the patient about the essential preventive nature of Aspirin after a TIA.
Correct Answer: C
Rationale: Explain that the Aspirin is ordered to decrease stroke risk.
Aspirin is prescribed post-TIA to reduce the likelihood of stroke by preventing blood clots. The patient’s understanding of the medication’s purpose is crucial for adherence and overall health management, especially after a transient ischemic event.
A: Document that the Aspirin was refused by the patient. This action does not address the patient’s misunderstanding or educate them about the importance of the medication for stroke prevention.
B: Tell the patient that the Aspirin is used to prevent aches. Misleading the patient by associating Aspirin with pain relief undermines its critical role in preventing serious vascular events like strokes.
D: Call the health care provider to clarify the medication order. Clarifying the order is unnecessary when the focus should be on educating the patient about the essential preventive nature of Aspirin after a TIA.
Question 17
Regular
A patient is admitted to the hospital with dysphagia and right-sided weakness that resolves in a few hours. The nurse will anticipate teaching the patient about
Correct!
Incorrect
The correct answer is: B
Rationale
B: Aspirin. The patient's symptoms suggest a transient ischemic attack (TIA), which often leads to temporary dysphagia and weakness. Aspirin is commonly prescribed to prevent future strokes after such episodes, making it a relevant teaching point.
A: Alteplase (tPA). This medication is utilized for acute ischemic strokes but is not indicated for TIAs, as the latter typically does not require thrombolytic therapy for resolution.
C: Warfarin. Warfarin is an anticoagulant used for long-term prevention of strokes in patients with specific conditions, not typically taught immediately following a TIA episode with temporary symptoms.
D: Nimodipine. This calcium channel blocker is primarily used to prevent vasospasm after subarachnoid hemorrhage, which does not relate to the patient's transient symptoms and immediate teaching needs.
Correct Answer: B
Rationale: B: Aspirin. The patient's symptoms suggest a transient ischemic attack (TIA), which often leads to temporary dysphagia and weakness. Aspirin is commonly prescribed to prevent future strokes after such episodes, making it a relevant teaching point.
A: Alteplase (tPA). This medication is utilized for acute ischemic strokes but is not indicated for TIAs, as the latter typically does not require thrombolytic therapy for resolution.
C: Warfarin. Warfarin is an anticoagulant used for long-term prevention of strokes in patients with specific conditions, not typically taught immediately following a TIA episode with temporary symptoms.
D: Nimodipine. This calcium channel blocker is primarily used to prevent vasospasm after subarachnoid hemorrhage, which does not relate to the patient's transient symptoms and immediate teaching needs.
Question 18
Regular
The nurse is caring for a patient with a left-sided brain stroke who suddenly bursts into tears when family members visit. Which of the following actions should the nurse implement?
Correct!
Incorrect
The correct answer is: D
Rationale
Teaching the family that emotional outbursts are common after strokes is essential for their understanding and support of the patient’s condition. This knowledge helps normalize the patient's experience and fosters an empathetic environment during recovery.
A: Use a calm voice to ask the patient to stop the crying behaviour. This approach may dismiss the patient’s feelings, potentially increasing emotional distress rather than providing comfort and understanding.
B: Explain to the family that depression is normal following a stroke. While depression can occur, this option does not address the immediate emotional reaction, which may be a temporary response instead.
C: Have the family members leave the patient alone for a few minutes. Isolating the patient may exacerbate feelings of loneliness and anxiety, further complicating their emotional state during a vulnerable moment.
Correct Answer: D
Rationale: Teaching the family that emotional outbursts are common after strokes is essential for their understanding and support of the patient’s condition. This knowledge helps normalize the patient's experience and fosters an empathetic environment during recovery.
A: Use a calm voice to ask the patient to stop the crying behaviour. This approach may dismiss the patient’s feelings, potentially increasing emotional distress rather than providing comfort and understanding.
B: Explain to the family that depression is normal following a stroke. While depression can occur, this option does not address the immediate emotional reaction, which may be a temporary response instead.
C: Have the family members leave the patient alone for a few minutes. Isolating the patient may exacerbate feelings of loneliness and anxiety, further complicating their emotional state during a vulnerable moment.
Question 19
Regular
The nurse obtains all of the following information about a patient in the clinic. When developing a plan to decrease stroke risk, which of the following risk factors is most important for the nurse to address?
Correct!
Incorrect
The correct answer is: D
Rationale
The patient's blood pressure is usually about 180/90 mm Hg. High blood pressure significantly increases the risk of stroke, making it imperative to prioritize its management in the patient's care plan.
A: The patient has a daily glass of wine to relax. While alcohol consumption can contribute to health risks, it is less critical than managing dangerously high blood pressure for stroke prevention.
B: The patient is 13 kg above the ideal weight. Excess weight can elevate stroke risk, yet it is secondary to the immediate threat posed by the patient’s elevated blood pressure levels.
C: The patient works at a desk and relaxes by watching television. Sedentary behavior contributes to health issues, but it does not present an acute risk like the patient's significantly high blood pressure does.
Correct Answer: D
Rationale: The patient's blood pressure is usually about 180/90 mm Hg. High blood pressure significantly increases the risk of stroke, making it imperative to prioritize its management in the patient's care plan.
A: The patient has a daily glass of wine to relax. While alcohol consumption can contribute to health risks, it is less critical than managing dangerously high blood pressure for stroke prevention.
B: The patient is 13 kg above the ideal weight. Excess weight can elevate stroke risk, yet it is secondary to the immediate threat posed by the patient’s elevated blood pressure levels.
C: The patient works at a desk and relaxes by watching television. Sedentary behavior contributes to health issues, but it does not present an acute risk like the patient's significantly high blood pressure does.
Question 20
Regular
The nurse is caring for a patient with sudden-onset right-sided weakness who has a CT scan and is diagnosed with an intracerebral hemorrhage. Which of the following information about the patient is most important to communicate to the health care provider?
Correct!
Incorrect
The correct answer is: D
Rationale
The patient has atrial fibrillation and takes warfarin. This information is crucial as it indicates a higher risk for bleeding complications, particularly in the context of an intracerebral hemorrhage, which may necessitate immediate intervention.
A: The patient's speech is difficult to understand. While this symptom is concerning and may indicate neurological impairment, it does not directly affect immediate management decisions related to hemorrhage.
B: The patient's blood pressure is 144/90 mm Hg. Although blood pressure is relevant for stroke management, this specific reading does not indicate an acute crisis that requires immediate communication.
C: The patient takes a diuretic because of a history of hypertension. This history is significant for overall health but does not directly influence the urgent care needed for an intracerebral hemorrhage.
Correct Answer: D
Rationale: The patient has atrial fibrillation and takes warfarin. This information is crucial as it indicates a higher risk for bleeding complications, particularly in the context of an intracerebral hemorrhage, which may necessitate immediate intervention.
A: The patient's speech is difficult to understand. While this symptom is concerning and may indicate neurological impairment, it does not directly affect immediate management decisions related to hemorrhage.
B: The patient's blood pressure is 144/90 mm Hg. Although blood pressure is relevant for stroke management, this specific reading does not indicate an acute crisis that requires immediate communication.
C: The patient takes a diuretic because of a history of hypertension. This history is significant for overall health but does not directly influence the urgent care needed for an intracerebral hemorrhage.
Question 21
Regular
The nurse is admitting a patient to the emergency department (ED) with right-sided weakness that began 90 minutes ago. Which of the following tests should be prioritized?
Correct!
Incorrect
The correct answer is: D
Rationale
Noncontrast computed tomography (CT) scan should be prioritized. This imaging test is crucial for quickly identifying any potential intracranial hemorrhage or ischemic stroke, which is vital in guiding urgent treatment decisions for the patient’s right-sided weakness.
A: Electrocardiogram (ECG) This test evaluates heart rhythm and function but does not provide immediate information regarding neurological conditions that could explain the patient's symptoms.
B: Complete blood count (CBC) While useful for assessing overall health and detecting infections or anemia, a CBC does not address the immediate neurological concerns presented by the patient’s symptoms.
C: Chest radiograph (chest x-ray) This imaging focuses on the thoracic cavity and does not contribute to diagnosing neurological deficits or conditions related to the patient’s acute right-sided weakness.
Correct Answer: D
Rationale: Noncontrast computed tomography (CT) scan should be prioritized. This imaging test is crucial for quickly identifying any potential intracranial hemorrhage or ischemic stroke, which is vital in guiding urgent treatment decisions for the patient’s right-sided weakness.
A: Electrocardiogram (ECG) This test evaluates heart rhythm and function but does not provide immediate information regarding neurological conditions that could explain the patient's symptoms.
B: Complete blood count (CBC) While useful for assessing overall health and detecting infections or anemia, a CBC does not address the immediate neurological concerns presented by the patient’s symptoms.
C: Chest radiograph (chest x-ray) This imaging focuses on the thoracic cavity and does not contribute to diagnosing neurological deficits or conditions related to the patient’s acute right-sided weakness.
Question 22
Regular
The nurse is caring for a patient with a stroke who has progressive development of neurological deficits with increasing weakness and decreased level of consciousness (LOC). Which of the following nursing diagnoses has the highest priority for the patient?
Correct!
Incorrect
The correct answer is: D
Rationale
Risk for aspiration as evidenced by impaired ability to swallow.
This diagnosis is the highest priority because the patient’s decreased level of consciousness and neurological deficits significantly compromise their swallowing ability, increasing the risk of aspiration. Immediate intervention is crucial to prevent potential respiratory complications and ensure the patient's safety during eating and drinking activities.
A: Impaired physical mobility related to decrease in muscle strength. While mobility issues are significant, they do not pose an immediate threat to life, unlike the risk of aspiration.
B: Risk for injury as evidenced by alteration in cognitive function. Cognitive alterations may lead to unsafe behaviors, but they do not have the same acute implications for health and safety as aspiration risk does.
C: Risk for impaired skin integrity as evidenced by pressure over bony prominence (immobility). Skin integrity concerns arise from immobility, yet they develop over time and are not as immediately critical as preventing aspiration in this situation.
Correct Answer: D
Rationale: Risk for aspiration as evidenced by impaired ability to swallow.
This diagnosis is the highest priority because the patient’s decreased level of consciousness and neurological deficits significantly compromise their swallowing ability, increasing the risk of aspiration. Immediate intervention is crucial to prevent potential respiratory complications and ensure the patient's safety during eating and drinking activities.
A: Impaired physical mobility related to decrease in muscle strength. While mobility issues are significant, they do not pose an immediate threat to life, unlike the risk of aspiration.
B: Risk for injury as evidenced by alteration in cognitive function. Cognitive alterations may lead to unsafe behaviors, but they do not have the same acute implications for health and safety as aspiration risk does.
C: Risk for impaired skin integrity as evidenced by pressure over bony prominence (immobility). Skin integrity concerns arise from immobility, yet they develop over time and are not as immediately critical as preventing aspiration in this situation.
Question 23
Regular
The nurse is caring for a patient who has had a subarachnoid hemorrhage and is being cared for in the intensive care unit. Which of the following information about vasospasms should the nurse be aware of when planning care?
Correct!
Incorrect
The correct answer is: D
Rationale
Peak time for occurrence is 7-10 days post bleed. Understanding the timing of vasospasms is crucial for effective monitoring and intervention following a subarachnoid hemorrhage, allowing for timely care adjustments.
A: The patient's blood pressure is 100/50 mm Hg. Low blood pressure may indicate compromised perfusion but does not provide specific insight into the timing or risk of vasospasms.
B: Endothelin will subside the vasospasm. Endothelin is actually a vasoconstrictor, which can exacerbate vasospasm instead of alleviating it, contradicting the need for effective management strategies.
C: The cerebrospinal fluid (CSF) report shows red blood cells (RBCs). While RBCs in CSF indicate bleeding, this information alone does not address the timing or risk of vasospasm occurrence.
Correct Answer: D
Rationale: Peak time for occurrence is 7-10 days post bleed. Understanding the timing of vasospasms is crucial for effective monitoring and intervention following a subarachnoid hemorrhage, allowing for timely care adjustments.
A: The patient's blood pressure is 100/50 mm Hg. Low blood pressure may indicate compromised perfusion but does not provide specific insight into the timing or risk of vasospasms.
B: Endothelin will subside the vasospasm. Endothelin is actually a vasoconstrictor, which can exacerbate vasospasm instead of alleviating it, contradicting the need for effective management strategies.
C: The cerebrospinal fluid (CSF) report shows red blood cells (RBCs). While RBCs in CSF indicate bleeding, this information alone does not address the timing or risk of vasospasm occurrence.
Question 24
Regular
The charge nurse is teaching a nursing student about immediate stroke care. Which of the following information should the nurse share with the nursing student?
Correct!
Incorrect
The correct answer is: B
Rationale
Antihypertensive medication is administered if the mean arterial pressure is >130 mm Hg. This guideline is crucial for managing blood pressure in stroke patients to prevent further complications and ensure optimal cerebral perfusion.
A: Hypotension post stroke is normal. Hypotension can lead to inadequate cerebral perfusion, which is not a typical expectation and can worsen stroke outcomes if not properly managed.
C: Diuretic ordered if the systolic BP is >160 mm Hg. Diuretics are not routinely initiated based solely on systolic blood pressure; they primarily address fluid overload, not acute blood pressure management post-stroke.
D: Withholding medications until the degree of dysphagia is known. While assessing dysphagia is essential, withholding all medications can delay critical treatment for stroke, potentially exacerbating the patient's condition.
Correct Answer: B
Rationale: Antihypertensive medication is administered if the mean arterial pressure is >130 mm Hg. This guideline is crucial for managing blood pressure in stroke patients to prevent further complications and ensure optimal cerebral perfusion.
A: Hypotension post stroke is normal. Hypotension can lead to inadequate cerebral perfusion, which is not a typical expectation and can worsen stroke outcomes if not properly managed.
C: Diuretic ordered if the systolic BP is >160 mm Hg. Diuretics are not routinely initiated based solely on systolic blood pressure; they primarily address fluid overload, not acute blood pressure management post-stroke.
D: Withholding medications until the degree of dysphagia is known. While assessing dysphagia is essential, withholding all medications can delay critical treatment for stroke, potentially exacerbating the patient's condition.
Question 25
Regular
The nurse is receiving a change-of-shift report. Which of the following patients should the nurse see first?
Correct!
Incorrect
The correct answer is: A
Rationale
A patient with right-sided weakness who has an infusion of tPA prescribed should be seen first. Administering tPA necessitates close monitoring due to its potential for serious complications, including bleeding. Evaluating this patient promptly ensures timely intervention, safeguarding against adverse events associated with thrombolytic therapy and addressing any neurological changes that may arise during treatment.
B: A patient who has atrial fibrillation and a new prescription for warfarin requires follow-up but does not present an immediate risk, allowing for later assessment after higher-priority patients.
C: A patient who experienced a transient ischemic attack yesterday who has a dose of Aspirin due needs monitoring but is not as critical as the tPA patient, making it a lower priority.
D: A patient with a subarachnoid hemorrhage 2 days ago who has nimodipine scheduled is stable enough for later evaluation, as their condition is less urgent compared to the tPA infusion.
Correct Answer: A
Rationale: A patient with right-sided weakness who has an infusion of tPA prescribed should be seen first. Administering tPA necessitates close monitoring due to its potential for serious complications, including bleeding. Evaluating this patient promptly ensures timely intervention, safeguarding against adverse events associated with thrombolytic therapy and addressing any neurological changes that may arise during treatment.
B: A patient who has atrial fibrillation and a new prescription for warfarin requires follow-up but does not present an immediate risk, allowing for later assessment after higher-priority patients.
C: A patient who experienced a transient ischemic attack yesterday who has a dose of Aspirin due needs monitoring but is not as critical as the tPA patient, making it a lower priority.
D: A patient with a subarachnoid hemorrhage 2 days ago who has nimodipine scheduled is stable enough for later evaluation, as their condition is less urgent compared to the tPA infusion.
Question 26
Regular
The nurse is caring for a patient who had a stroke and is in the acute phase of care. Which of the following systems is priority?
Correct!
Incorrect
The correct answer is: B
Rationale
B: Respiratory system. In the acute phase of care following a stroke, ensuring adequate respiratory function is crucial, as compromised breathing can lead to severe complications, impacting overall recovery and prognosis.
A: Neurological system. While monitoring neurological status is vital in stroke care, immediate respiratory support takes precedence to prevent hypoxia and associated complications during this critical period.
C: Gastro-intestinal system. Although gastrointestinal management is important, it does not take priority over respiratory needs, especially when the patient's airway and breathing are at risk post-stroke.
D: Genito-urinary system. Addressing genito-urinary concerns is necessary but secondary to the urgent requirement of maintaining respiratory stability, which directly affects patient survival and recovery outcomes.
Correct Answer: B
Rationale: B: Respiratory system. In the acute phase of care following a stroke, ensuring adequate respiratory function is crucial, as compromised breathing can lead to severe complications, impacting overall recovery and prognosis.
A: Neurological system. While monitoring neurological status is vital in stroke care, immediate respiratory support takes precedence to prevent hypoxia and associated complications during this critical period.
C: Gastro-intestinal system. Although gastrointestinal management is important, it does not take priority over respiratory needs, especially when the patient's airway and breathing are at risk post-stroke.
D: Genito-urinary system. Addressing genito-urinary concerns is necessary but secondary to the urgent requirement of maintaining respiratory stability, which directly affects patient survival and recovery outcomes.
Question 27
Regular
The nurse is admitting a patient with left-sided hemiparesis who has arrived by ambulance to the emergency department. Which of the following actions should the nurse take first?
Correct!
Incorrect
The correct answer is: A
Rationale
Check the respiratory rate.
Assessing the respiratory rate is crucial as it provides immediate insight into the patient's respiratory status, which can quickly deteriorate, especially in cases of neurological deficits like left-sided hemiparesis.
B: Monitor the blood pressure. Blood pressure monitoring is important but secondary to ensuring the patient's airway and breathing are stable in an emergency setting.
C: Send the patient for a CT scan. A CT scan is significant for diagnosing potential strokes but should follow initial assessments of vital signs and stability.
D: Obtain the Glasgow Coma Scale score. While assessing consciousness is vital, addressing respiratory needs takes precedence to prevent critical complications from arising.
Correct Answer: A
Rationale: Check the respiratory rate.
Assessing the respiratory rate is crucial as it provides immediate insight into the patient's respiratory status, which can quickly deteriorate, especially in cases of neurological deficits like left-sided hemiparesis.
B: Monitor the blood pressure. Blood pressure monitoring is important but secondary to ensuring the patient's airway and breathing are stable in an emergency setting.
C: Send the patient for a CT scan. A CT scan is significant for diagnosing potential strokes but should follow initial assessments of vital signs and stability.
D: Obtain the Glasgow Coma Scale score. While assessing consciousness is vital, addressing respiratory needs takes precedence to prevent critical complications from arising.
Question 28
Drag and Drop
The nurse is admitting a patient who began experiencing right-sided arm and leg weakness to the emergency department. In which order should the nurse implement these actions included in the stroke protocol?
Drag and drop to arrange in correct order:
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.
Correct!
Incorrect
The correct answer is: C,D,A,B
Rationale
Administer oxygen to keep O2 saturation >95%. Initiating oxygen therapy is crucial to ensure adequate oxygen supply to the brain, especially in stroke patients, before further assessments and treatments are performed.
D: Use National Institute of Health Stroke Scale to assess patient. While assessment is vital, it should follow the stabilization of oxygen levels to ensure the patient is adequately supported during evaluation.
A: Obtain CT scan without contrast. Imaging is essential for diagnosis but should occur after ensuring the patient’s oxygen levels are stable and appropriate assessments have been completed.
B: Infuse tissue plasminogen activator (tPA). Administering tPA is a critical intervention but is contingent upon the patient's condition being stabilized and ensuring proper assessment and imaging have been conducted first.
Correct Answer: C,D,A,B
Rationale: Administer oxygen to keep O2 saturation >95%. Initiating oxygen therapy is crucial to ensure adequate oxygen supply to the brain, especially in stroke patients, before further assessments and treatments are performed.
D: Use National Institute of Health Stroke Scale to assess patient. While assessment is vital, it should follow the stabilization of oxygen levels to ensure the patient is adequately supported during evaluation.
A: Obtain CT scan without contrast. Imaging is essential for diagnosis but should occur after ensuring the patient’s oxygen levels are stable and appropriate assessments have been completed.
B: Infuse tissue plasminogen activator (tPA). Administering tPA is a critical intervention but is contingent upon the patient's condition being stabilized and ensuring proper assessment and imaging have been conducted first.