Stroke & IICP

The RN is caring for a patient that was brought to the emergency department following a coronary artery stenting procedure. Which assessment finding would be priority for the nurse to address?

• HR 102bpm

• Aphasia

• BP 144/86

• Fine crackles in lung bases

Tags

prioritization

manifestations

A patient is complaining of sudden-onset right sided weakness following an intracerebral hemorrhage. Which information about the patient is most important to communicate to the provider?

• The patient's speech is slurred and incoherent.

• The patient's BP is 140/90.

• The patient is currently taking furosemide (Lasix)

• The patient is currently taking warfarin (Coumadin).

Tags

pharmacology

prioritization

The RN is providing education to the family of a patient following a stroke. The patient is experiencing homonymous hemianopsia and the family would like to help the patient overcome this deficit. Which statement by the family indicates effective teaching has taken place?

• "We need to discourage him from wearing eyeglasses."

• "We need to place objects on the impaired side to improve his vision."

• "We need to remind him to turn his head to scan the impaired field of vision."

• "We need to approach him from the impaired side of his body."

Tags

education

manifestations

Four days following a stroke, a patient is ordered oral fluids and feedings to be started today. Prior to initiating this order, which action should the nurse take?

• Check the patient's gag reflex

• Order a soft diet

• Raise the head of the bed to a semi-fowler's position

• evaluate the patient's swallowing with small amounts of crushed ice

Tags

prioritization

The RN is caring for a patient who was admitted due to experiencing stroke symptoms. Which action can be delegated to the UAP?

• assess the patient's gag & cough reflexes

• inquire about when the stroke symptoms began.

• perform q4hr neuro checks

• infuse IV metoprolol

Tags

delegation

Of the following patients, the RN recognizes that the one with the highest stroke risk is:

• 45-year old obese Native American male

• 35-year old Asian American female that smokes

• 32-year old white female taking oral contraceptives

• 65-year old African American male with hypertension

Tags

risk factors

A patient is brought to the emergency department with left hemiplegia. To determine the location and type of stroke, the RN will anticipate an order for which diagnostic test?

• CT scan

• lumbar puncture

• cerebral arteriogram

• positron emission tomography scan (PET)

Tags

diagnostic tests

Which of the following meals would be most appropriate for a patient following a thrombotic ischemic stroke?

• Grape juice, whole wheat toast, and a hard boiled egg.

• Strawberry jello, mashed potatoes, and a protein milkshake.

• Turkey sandwich on wheat bread, celery sticks, and iced tea.

• Chicken noodle soup, mango smoothie, and grapes.

Tags

nursing interventions

diet

A patient's wife asks the nurse why her husband did not receive tPA when he arrived to the emergency department following a stroke. Which of the following patient situations best describes the reasoning for not giving tPA?

• Patient arrived 1 hour after the onset of stroke symptoms.

• The patient was involved in a motor vehicle Collison.

• The patient has a history of smoking and coronary artery disease.

• The patient is currently taking metformin for diabetes.

Tags

education

pharmacology

The nurse is caring for an unconscious patient with increased ICP following a stroke. What action should the nurse take before performing ROM exercises?

• Place the patient in soft restraints to avoid injury.

• Administer a CNS depressant to lightly sedate the patient.

• Schedule exercises spread out and less frequently due to prevent IICP.

• Cluster patient care by performing ROM after medication administration.

Tags

nursing interventions

prioritization