Ch.41-Critical Care of Patients With Neurologic Emergencies

A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak, and felt numbness in

his left leg. Currently the client’s neurologic examination is normal. About what drug would the nurse plan to teach the patient?

• Alteplase

• Clopidogrel

• Heparin sodium

• Mannitol

Answer explanation

This client’s signs and symptoms are consistent with a transient ischemic attack, and the client would likely be prescribed aspirin or

clopidogrel to prevent platelet aggregation on discharge. Alteplase is used for ischemic stroke. Heparin and mannitol are not used

for this condition.

The nurse is preparing a client for discharge from the emergency department after experiencing a transient ischemic attack (TIA).

Before discharge, which factor would the nurse identify as placing the client at high risk for a stroke?

• Age greater than or equal to 75

• Blood pressure greater than or equal to 160/95

• Unilateral weakness during a TIA

• TIA symptoms lasting less than a minute

Answer explanation

The client who has a TIA is at risk for a stroke is he or she has one-sided (unilateral) weakness during a TIA. Risk factors also

include an age greater than or equal to 60, blood pressure greater than or equal to 140/90 (either or both systolic and diastolic),

and/or a long duration of TIA symptoms. One minute is not a very long time for symptoms to occur.

The nurse is taking a history from a daughter about her father’s onset of stroke signs and symptoms. Which statement by the

daughter indicates that the client likely had an embolic stroke?

• Client’s symptoms occurred slowly over several hours.

• Client because increasingly lethargic and drowsy.

• Client reported severe headache before other symptoms.

• Client has a long history of atrial fibrillation.

Answer explanation

The major cause of embolic strokes is a history of heart disease, especially atrial fibrillation. Most clients who have an embolic

stroke have acute sudden neurologic symptoms but stay alert rather than lethargic. Decreasing level of consciousness and severe

headache are more common in clients who have hemorrhagic strokes.

A client is admitted with a sudden decline in level of consciousness. What is the nursing action at this time?

• Assess the client for hypoglycemia and hypoxia.

• Place the client on his or her side.

• Prepare for administration of a fibrinolytic agent.

• Start a continuous IV heparin sodium infusion.

Answer explanation

The cause of a sudden decline in level of consciousness may or may not be related to a neurologic health problem. Therefore, the

client must be evaluated for other common causes, especially hypoglycemia and hypoxia. Placing the client on his or her side may

be helpful to prevent aspiration in case the client experiences vomiting, but the clinical situation does not indicate that the client has

nausea or vomiting. Administering either an anticoagulant like heparin or a fibrinolytic agent assumes that the client has an acute

ischemic stroke, which has not been confirmed through imaging tests.

The nurse is teaching assistive personnel (AP) about care for a male client diagnosed with acute ischemic stroke and left-sided

weakness. Which statement by the AP indicates understanding of the nurse’s teaching?

• “I will use “yes” and “no” questions when communicating with the client.”

• “I will remind the client frequently to not get out of bed without help.”

• “I will offer a urinal every hour to the client due to incontinence.”

• “I will feed the client slowly using soft or pureed foods.”

Answer explanation

The client who has left-sided weakness has likely had a right-sided stroke in the brain. Clients who have strokes on the right side of

the brain tend to be very impulsive and exhibit poor judgment. Therefore, to keep the client safe, the staff will need to remind the

client to stay in bed unless he has assistance to prevent falling. There is no evidence in the clinical situation that the client has

aphasia (which is less common in those with right-sided strokes), difficulty swallowing, or urinary incontinence.

A nurse receives a hand-off report on a female client who had a left-sided stroke with homonymous hemianopsia. What action by

the nurse is most appropriate for this client?

• Assess for bladder and bowel retention and/or incontinence.

• Listen to the client’s lungs after eating or drinking for diminished breath sounds.

• Support the client’s left side when sitting in a chair or in bed.

• Remind the client to move her head from side to side to increase her visual field.

Answer explanation

Homonymous hemianopsia is blindness on the same side of both eyes. The client must turn his or her head to see the entire visual

field. This condition is not related to bladder function, difficulty swallowing, or lack of trunk control.

A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for

the nurse to obtain?

• Other medical conditions

• Loss of bladder control

• Progression of symptoms

• Time of symptom onset

Answer explanation

The time limit for initiating fibrinolytic therapy for a stroke is 3 to 4.5 hours, so the exact time of symptom onset is the most

important information for this client. The other information is not as critical.

The nurse is preparing to administer IV alteplase for a client diagnosed with an acute ischemic stroke. Which statement is correct

about the administration of this drug?

• The recommended time for drug administration is within 90 minutes after

  admission to the emergency department.

• The drug is given in a bolus over the first 3 minutes followed by a continuous

  infusion.

• The maximum dosage of the drug, including the bolus, is 120 mg intravenously.

• The drug is not given to clients who are already on anticoagulant or antiplatelet

  therapy.

Answer explanation

Alteplase is a thrombolytic which dissolves clots and can cause bleeding as an adverse effect. Clients who are already taking an

anticoagulant or antiplatelet agent are at risk for bleeding and therefore they are not candidates for alteplase therapy.

A client is receiving IV alteplase and reports a sudden severe headache. What is the nurse’s first action?

• Perform a comprehensive pain assessment.

• Discontinue the infusion of the drug.

• Conduct a neurologic assessment.

• Administer an antihypertensive drug.

Answer explanation

A severe headache may indicate that the client’s blood pressure has markedly increased and, therefore, the drug should be stopped

immediately as the first action. The nurse would then perform the appropriate assessments and possibly administer an

antihypertensive medication.

A client experiences impaired swallowing after a stroke and has worked with speech–language pathology on eating. What nursing

assessment best indicates that the expected outcome for this problem has been met?

• Chooses preferred items from the menu.

• Eats 75 to 100% of all meals and snacks.

• Has clear lung sounds on auscultation.

• Gains 2 lb (1 kg) after 1 week.

Answer explanation

Impaired swallowing can lead to aspiration and then aspiration pneumonia, so the expected outcome for this problem is to

experience no aspiration. Clear lung sounds is the best indicator that aspiration has not occurred. Choosing menu items is not

related to this problem. Eating meals does not indicate that the client is not still aspirating. A weight gain indicates improved

nutrition but still does not show a lack of aspiration.