Podcast
Questions and Answers
A nurse is assessing a patient suspected of having a stroke. Which finding requires the nurse to act immediately?
A nurse is assessing a patient suspected of having a stroke. Which finding requires the nurse to act immediately?
- Sudden unilateral facial droop (correct)
- Blood pressure of 140/90 mmHg
- Slurred speech that resolves in 15 minutes
- Complaint of a mild headache
A patient arrives in the emergency department with left-sided weakness and difficulty speaking. Which diagnostic test should the nurse anticipate first?
A patient arrives in the emergency department with left-sided weakness and difficulty speaking. Which diagnostic test should the nurse anticipate first?
- Non-contrast CT scan of the head (correct)
- Magnetic resonance imaging (MRI)
- Electrocardiogram (ECG)
- Lumbar puncture
Which statement by a patient with modifiable risk factors for stroke indicates understanding of prevention strategies?
Which statement by a patient with modifiable risk factors for stroke indicates understanding of prevention strategies?
- I only need to take my blood pressure medication when I feel dizzy.
- I can eat fried foods in moderation since I'm taking cholesterol medication.
- I'll start smoking fewer cigarettes per day instead of quitting completely.
- I should walk at least 30 minutes most days of the week. (correct)
The nurse is caring for a patient receiving alteplase (tPA) for an acute ischemic stroke. Which finding requires immediate intervention?
The nurse is caring for a patient receiving alteplase (tPA) for an acute ischemic stroke. Which finding requires immediate intervention?
A nurse is providing discharge teaching to a patient with a history of a transient ischemic attack (TIA). Which statement indicates the need for further teaching?
A nurse is providing discharge teaching to a patient with a history of a transient ischemic attack (TIA). Which statement indicates the need for further teaching?
A patient with a hemorrhagic stroke is at risk for increased intracranial pressure (ICP). Which interventions should the nurse implement? (Select all that apply.)
A patient with a hemorrhagic stroke is at risk for increased intracranial pressure (ICP). Which interventions should the nurse implement? (Select all that apply.)
A nurse is assessing a stroke patient for possible dysphagia. Which findings indicate a high risk for aspiration? (Select all that apply.)
A nurse is assessing a stroke patient for possible dysphagia. Which findings indicate a high risk for aspiration? (Select all that apply.)
A nurse is preparing to administer medications to a stroke patient. Which drugs may be used in the acute phase of an ischemic stroke? (Select all that apply.)
A nurse is preparing to administer medications to a stroke patient. Which drugs may be used in the acute phase of an ischemic stroke? (Select all that apply.)
A nurse is educating a patient with a history of ischemic stroke about lifestyle modifications. Which recommendations are appropriate? (Select all that apply.)
A nurse is educating a patient with a history of ischemic stroke about lifestyle modifications. Which recommendations are appropriate? (Select all that apply.)
The nurse is assessing a stroke patient for neurological deficits. Which findings are consistent with a right-sided stroke? (Select all that apply.)
The nurse is assessing a stroke patient for neurological deficits. Which findings are consistent with a right-sided stroke? (Select all that apply.)
A patient diagnosed with an embolic stroke asks how it happened. Which explanation by the nurse is correct?
A patient diagnosed with an embolic stroke asks how it happened. Which explanation by the nurse is correct?
The nurse is caring for a patient who experienced a left-sided ischemic stroke. Which assessment finding is expected?
The nurse is caring for a patient who experienced a left-sided ischemic stroke. Which assessment finding is expected?
Which of the following medications should the nurse question for a patient with an acute hemorrhagic stroke?
Which of the following medications should the nurse question for a patient with an acute hemorrhagic stroke?
A patient with a history of atrial fibrillation is prescribed warfarin to prevent stroke. What should the nurse monitor?
A patient with a history of atrial fibrillation is prescribed warfarin to prevent stroke. What should the nurse monitor?
A patient with expressive aphasia is frustrated. Which action by the nurse is most appropriate?
A patient with expressive aphasia is frustrated. Which action by the nurse is most appropriate?
The nurse is reviewing orders for a stroke patient. Which order should the nurse question?
The nurse is reviewing orders for a stroke patient. Which order should the nurse question?
Which laboratory result is most concerning for a patient receiving tPA therapy?
Which laboratory result is most concerning for a patient receiving tPA therapy?
Which is the most important nursing action before administering tPA?
Which is the most important nursing action before administering tPA?
Which intervention is most appropriate for a patient with unilateral neglect following a right-sided stroke?
Which intervention is most appropriate for a patient with unilateral neglect following a right-sided stroke?
The nurse is monitoring a stroke patient for complications. Which findings indicate worsening increased intracranial pressure (ICP)? (Select all that apply.)
The nurse is monitoring a stroke patient for complications. Which findings indicate worsening increased intracranial pressure (ICP)? (Select all that apply.)
Which dietary recommendations are appropriate for a stroke patient with dysphagia? (Select all that apply.)
Which dietary recommendations are appropriate for a stroke patient with dysphagia? (Select all that apply.)
A nurse is preparing to administer clopidogrel to a patient with a history of ischemic stroke. Which statement by the patient requires further education?
A nurse is preparing to administer clopidogrel to a patient with a history of ischemic stroke. Which statement by the patient requires further education?
Which patient is at highest risk for an ischemic stroke?
Which patient is at highest risk for an ischemic stroke?
A nurse is monitoring a patient with an evolving ischemic stroke. Which finding requires the most immediate intervention?
A nurse is monitoring a patient with an evolving ischemic stroke. Which finding requires the most immediate intervention?
The nurse is educating a patient about secondary stroke prevention. Which statement indicates a need for further teaching?
The nurse is educating a patient about secondary stroke prevention. Which statement indicates a need for further teaching?
The nurse is planning care for a patient with hemiplegia following a stroke. Which intervention is most appropriate to prevent contractures?
The nurse is planning care for a patient with hemiplegia following a stroke. Which intervention is most appropriate to prevent contractures?
The nurse is assessing a patient who had a right-sided stroke. Which findings are expected? (Select all that apply.)
The nurse is assessing a patient who had a right-sided stroke. Which findings are expected? (Select all that apply.)
Which assessments should the nurse perform before administering tPA? (Select all that apply.)
Which assessments should the nurse perform before administering tPA? (Select all that apply.)
A nurse is teaching a patient about modifiable stroke risk factors. Which factors should be addressed? (Select all that apply.)
A nurse is teaching a patient about modifiable stroke risk factors. Which factors should be addressed? (Select all that apply.)
The nurse is caring for a stroke patient receiving mechanical ventilation. Which intervention is most important?
The nurse is caring for a stroke patient receiving mechanical ventilation. Which intervention is most important?
The nurse is preparing to discharge a stroke patient. Which interventions promote safety at home? (Select all that apply.)
The nurse is preparing to discharge a stroke patient. Which interventions promote safety at home? (Select all that apply.)
Which nursing interventions are appropriate for a patient with impaired swallowing? (Select all that apply.)
Which nursing interventions are appropriate for a patient with impaired swallowing? (Select all that apply.)
Which statement by the family of a stroke patient indicates a need for further teaching?
Which statement by the family of a stroke patient indicates a need for further teaching?
The nurse notes a new-onset irregular heartbeat in a stroke patient. What is the priority action?
The nurse notes a new-onset irregular heartbeat in a stroke patient. What is the priority action?
The nurse is caring for a patient with left-sided hemiparesis following a stroke. Which intervention is most effective in promoting mobility?
The nurse is caring for a patient with left-sided hemiparesis following a stroke. Which intervention is most effective in promoting mobility?
The nurse is teaching a stroke patient about new prescriptions for secondary prevention. Which statement requires further teaching?
The nurse is teaching a stroke patient about new prescriptions for secondary prevention. Which statement requires further teaching?
A patient is recovering from a stroke and has residual dysphagia. Which finding requires immediate intervention?
A patient is recovering from a stroke and has residual dysphagia. Which finding requires immediate intervention?
The nurse is assessing a stroke patient for complications. Which findings suggest deep vein thrombosis (DVT)? (Select all that apply.)
The nurse is assessing a stroke patient for complications. Which findings suggest deep vein thrombosis (DVT)? (Select all that apply.)
The nurse is developing a plan of care for a stroke patient with homonymous hemianopia. Which interventions are appropriate? (Select all that apply.)
The nurse is developing a plan of care for a stroke patient with homonymous hemianopia. Which interventions are appropriate? (Select all that apply.)
The nurse is evaluating the effectiveness of stroke rehabilitation. Which outcomes indicate improvement? (Select all that apply.)
The nurse is evaluating the effectiveness of stroke rehabilitation. Which outcomes indicate improvement? (Select all that apply.)
Flashcards
Facial Droop in Stroke
Facial Droop in Stroke
A sudden, unilateral facial droop is a key sign of an acute stroke requiring immediate action.
Non-contrast CT scan
Non-contrast CT scan
This imaging differentiates between ischemic and hemorrhagic stroke to guide treatment, like tPA.
Stroke Prevention: Exercise
Stroke Prevention: Exercise
Regular exercise lowers blood pressure and improves cholesterol levels, reducing overall stroke risk.
tPA and Hypertension
tPA and Hypertension
Uncontrolled hypertension increases the risk of intracranial hemorrhage following tPA administration.
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Transient Ischemic Attack (TIA)
Transient Ischemic Attack (TIA)
TIAs are warning signs of a future stroke, making lifestyle changes and medical management essential.
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Hemorrhagic Stroke Interventions
Hemorrhagic Stroke Interventions
These interventions can aid in managing ICP, including elevating HOB to 30 degrees, minimizing stimuli, and preventing straining.
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Dysphagia Signs
Dysphagia Signs
Patients with dysphagia often exhibit wet voice, coughing, drooling, and delayed swallowing, indicating high aspiration risk.
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Embolic Stroke
Embolic Stroke
This occurs when a clot or debris travels from another part of the body (e.g., atrial fibrillation, heart valves) and blocks cerebral blood flow.
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Left-Sided Stroke Deficit
Left-Sided Stroke Deficit
Damage on one side of the brain affects the opposite side of the body
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Warfarin Monitoring
Warfarin Monitoring
Warfarin (Coumadin) requires this type of monitoring to maintain therapeutic anticoagulation and prevent ischemic strokes caused by atrial fibrillation.
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Expressive Aphasia
Expressive Aphasia
This affects speech production, but the patient may understand; use communication boards for better communication.
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tPA Administration
tPA Administration
Medication used within 3-4.5 hours of symptom onset to dissolve clots and improve blood flow
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tPA Contraindications
tPA Contraindications
tPA is contraindicated when they increase bleeding risk in conditions like thrombocytopenia
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Importance of Last Known Time
Importance of Last Known Time
Determines a patient's eligibility for tPA administration in an acute stroke
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Unilateral Neglect
Unilateral Neglect
Patients scan towards the affected side to counteract one sided perception
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Cerebrovascular Accident (CVA) NCLEX-Style Exam
- Sudden unilateral facial droop requires immediate action because it is a hallmark sign of an acute stroke.
- Slurred speech that resolves in 15 minutes may indicate a transient ischemic attack (TIA).
- Prioritize recognizing acute stroke signs and activating the emergency response.
- A non-contrast CT scan is the first imaging modality to differentiate ischemic stroke from hemorrhagic stroke.
- A non-contrast CT guides treatment options like tPA administration.
- Regular exercise lowers blood pressure, improves cholesterol levels, and reduces stroke risk.
- Regular exercise shows correct understanding of risk management.
- Uncontrolled hypertension increases the risk of intracranial hemorrhage following tPA administration.
- A BP > 185/110 mmHg is a contraindication for tPA therapy.
- TIAs are warning signs of a future stroke.
- Up to 15% of people with a TIA develop a major stroke within 3 months.
- Lifestyle changes and medical management are essential after TIA.
- Managing ICP includes elevating the HOB to 30 degrees, minimizing stimuli, and preventing straining.
- Thrombolytics (e.g., tPA) are contraindicated in hemorrhagic stroke.
- Patients with dysphagia often exhibit wet voice, coughing, drooling, and delayed swallowing.
- Aspiration precautions (e.g., thickened liquids, speech therapy) are necessary to prevent aspiration pneumonia.
- Alteplase (tPA) is used within 3–4.5 hours of an ischemic stroke.
- Aspirin and BP control are also critical in the acute phase of an ischemic stroke.
- Warfarin and IV heparin are not used acutely but may be prescribed later for secondary prevention.
- A heart-healthy diet, exercise, BP control, and smoking cessation reduce stroke risk.
- Excess alcohol increases stroke risk due to hypertension and arrhythmias.
- Right-sided strokes cause left-sided weakness, impulsivity, spatial deficits, and unilateral neglect.
- Expressive aphasia (Broca's aphasia) is more common in left-sided strokes (dominant hemisphere).
- An embolic stroke occurs when a clot or debris travels from another part of the body (e.g., atrial fibrillation, heart valves) and blocks cerebral blood flow.
- A left-sided stroke affects the right side of the body causing right-sided hemiplegia (paralysis) or hemiparesis (weakness).
- tPA is contraindicated in hemorrhagic stroke because it increases the risk of bleeding.
- Antihypertensives (labetalol, nicardipine) and mannitol to reduce ICP may be used.
- Warfarin (Coumadin) requires INR monitoring to maintain therapeutic anticoagulation.
- Warfarin prevents ischemic strokes caused by atrial fibrillation.
- Expressive aphasia affects speech production, but the patient may understand.
- Alternative communication methods, such as a communication board, help reduce frustration.
- IV heparin bolus is not recommended for acute ischemic stroke due to the risk of hemorrhagic conversion.
- Antiplatelets like aspirin are used instead of IV heparin bolus.
- Low platelet counts (<100,000/mm³) increase bleeding risk.
- tPA is contraindicated in thrombocytopenia due to a high risk of hemorrhage.
- tPA must be given within 3–4.5 hours of symptom onset for ischemic stroke.
- The last known normal time determines eligibility for tPA.
- Patients with unilateral neglect (more common in right-sided strokes) should be encouraged to scan the affected side to improve awareness and prevent injury.
- Signs of increased ICP include decreased LOC, widening pulse pressure, and irregular breathing patterns (e.g., Cheyne-Stokes respiration).
- Thickened liquids and pureed foods reduce aspiration risk.
- Avoid straws and thin liquids for stroke patients with dysphagia.
- Clopidogrel (Plavix) is a preventative antiplatelet medication, not an emergency stroke treatment.
- Clopidogrel reduces future clot formation but does not treat acute stroke symptoms.
- Atrial fibrillation increases stroke risk fivefold due to clot formation in the atria.
- Without anticoagulation, clots can embolize and cause an ischemic stroke.
- Sudden changes in mental status may indicate stroke progression, hemorrhagic transformation, or increased ICP, requiring immediate intervention.
- A diet high in saturated fats increases the risk of atherosclerosis, which contributes to stroke recurrence.
- A heart-healthy diet is essential for stroke prevention.
- Contractures develop quickly in stroke patients due to muscle inactivity.
- Splints and ROM exercises help maintain joint mobility and prevent contractures.
- Right-sided strokes affect the left side of the body and cause impulsivity, poor judgment, and spatial-perceptual deficits.
- Expressive aphasia is more common in left-sided strokes.
- tPA administration requires assessing the last known normal time, ruling out hemorrhagic stroke with a CT scan, and checking BP and coagulation studies to prevent bleeding complications.
- Smoking, hypertension, obesity, and high cholesterol are modifiable risk factors for stroke.
- Genetics cannot be changed but should be considered in risk assessment.
- High PaCO2 causes vasodilation and increases ICP, worsening stroke outcomes.
- Maintaining normocapnia (PaCO2: 35-45 mmHg) helps prevent cerebral edema.
- Fall prevention measures include removing tripping hazards, using grab bars, wearing non-slip shoes, and ensuring clear walking paths.
- High-Fowler's positioning, slow eating, thickened liquids, and speech therapy referral reduce aspiration risk.
- Approaching from the unaffected side helps patients compensate for neglect and process information more effectively.
- New-onset atrial fibrillation increases stroke risk due to clot formation and may require anticoagulation therapy.
- Passive ROM exercises prevent muscle atrophy, improve circulation, and maintain joint mobility.
- Immobilization increases contracture risk, and bed rest worsens deconditioning.
- Statins reduce stroke risk by lowering cholesterol and stabilizing plaques.
- Statins should not be discontinued without medical advice, even if cholesterol improves.
- Coughing while drinking indicates aspiration risk, which can lead to aspiration pneumonia.
- Unilateral leg swelling, pain, warmth, and redness due to clot formation suggest DVT.
- Bilateral edema is more likely due to heart failure, and peripheral pulses are not usually affected in DVT.
- Homonymous hemianopia causes visual field loss on the same side in both eyes.
- Scanning techniques, safety measures, and approaching from the unaffected side help compensate for Homonymous hemianopia.
- Progress in rehabilitation includes independent ADLs, effective communication, and improved mobility.
- Avoidance and refusal of therapy or medications indicate psychological distress requiring intervention.
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