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Cerebrovascular Accident (Stroke) Katie Crawford Beverly Grimme Clare Gruneisen Jamie Thomas Dixie Williams

2. Insert Stroke Zone Video 3. Is there treatment that can be initiated in the ED to stop a CVA from progressing? Yes, clot busting medications such as TPA can expedite clot fibrinolysis (if given within 3 hours).

4. Signs/Symptoms facial droop unilateral muscle weakness slurred speech sudden confusion severe headache Which of the following is not a symptom of CVA? 1. Headache 2. Lethargy 3. Lumbarpain 4. Blurredvision

5. Your co-worker states, I always heard that PAF is a precursor to stroke. Is this statement true or false? True. There is overwhelming evidence to link PAF to increased stroke risk. Studies have shown that patients with PAF should be on chronic anticoagulation.

6. What other information would be necessary for evaluating the cause for the CVA? N.T. had a history of PAF; an ECG would be necessary to evaluate rhythm status. An echo- cardiogram would be helpful for evaluating the possibility of thrombi in the atria or ventricle. A carotid US is used to identify any atherosclerotic plaques.

7. Why was the initial CT scan negative for stroke? Cell death does not occur immediately following a CVA. It may take up to 12 hours for cell death to be detected by CT. MRI may be a better option, along with a complete history and physical.

8. What lab test may be abnormal during CVA? The isoenzyme CK-BB is measured to detect brain tissue injury.

9. Insert antiplatelet commercial 10. N.T.s physician has ordered a modified barium swallow study and referral for speech -language pathologist (SLP), occupational therapist (OT), and registered dietitian (RD). Give the rationale for these orders. Symptoms of probable dysphagia were noted on the initial exam. A modified barium swallow study is a video showing how food is taken into the mouth, chewed, propelled to the posterior pharynx, and swallowed. The SLP makes the diagnosis of dysphagia, recommends the safest position of the head for eating, and recommends the optimal food texture and liquid consistency to prevent aspiration. The OT determines whether any adaptive feeding devices are necessary to promote independent eating. The RD teaches family members how to prepare meals accord- ing to the prescribed food texture and liquid consistency.

11. If her deficits are temporary, how long might it take before they are completely reversed? Maximum resolution of mild deficits usually takes between 6 months and 1 year.

12. N.T. is not on HRT post-CVA. Why would this medication be discontinued? Studies have shown that HRT can actually contribute to clot formation or hemorrhagic stroke. Therefore, when a CVA has occurred in a woman who is on HRT and has been on it for longer than 5 years, it may be stopped as a protective measure against further platelet aggregation and vascular risk.

13. Is there any benefit from continuing simvastatin after her CVA? HMG-CoA reductase inhibitors, commonly called statins, have been shown to dramatically reduce the incidence of first and second CVA. It is believed that statins stabilize the endothelial wall and prevent plaque ruptures.

14. Why was N.T. placed on clopidogrel post-CVA? Clopidogrel (Plavix) plus aspirin is currently recommended to prevent platelet aggregation and thereby prevent CVA and secondary CVA.

15. N.T.s BP should be well controlled. What BP level should be considered normal for her, based on the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)? JNC 7 guidelines consider a BP of 120/80 or less mm Hg or below to be normal for patients without renal or diabetic disease.

16. Nursing Dx Ineffective Health Mainenance RT deficient knowledge regarding self-care after CVA Suggested NOC outcomes: Health beliefs: perceived resources, health-promoting behavior, healthseeking behavior Suggested NIC interventions: Health education, health system guidance, support system enhancement (Refer to OT, RD, give community resources)

17. Nursing Dx Impaired Physical Mobility RT loss of balance and coordination Suggested NOC outcomes:Ambulation, Ambulation: Wheelchair, Mobility, Self-Care: Activities of Daily Living (ADLs), Instrumental Activities of Daily Living (IADLs), Transfer Performance Suggested NIC interventions:Exercise Therapy: Ambulation, Joint Mobility, Positioning

18. Nursing Dx Chronic Confusion RT cerebral vascular attack Suggested NOC outcome: Cognition, Cognitive Orientation, Distorted Thought Self-Control Suggested NIC interventions: Cognition as evidenced by the following indicators: Cognitive orientation/Communicates clearly/Comprehends the meaning of situations/Attentiveness/Concentration (Rate the outcome and indicators of Cognition: 1 severely compromised, 2 substantially compromised, 3 moderately compromised, 4 mildly compromised, 5 not compromised)

19. NCLEX Time! 1 2 3 4 5 6 7 8 9 10 20. 1. What lab test may be abnormal during CVA? 1. CK-BB 2. Hemoglobin A1C 3. BUN level 4. Blood Type Answer

21. * 1. Creatine Kinase-BB is found in the brain and shows neural cell injury. Back 22. 2. 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. Answer

23. 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. Back

24. 3. 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. Answer

25. 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. Back

26. 4. During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to control the clients: 1. Pulse 2. Respirations 3. Blood pressure 4. Temperature Answer

27. 3. Controlling the blood pressure is critical because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy. Back

28. 5. 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 Answer

29. 2. It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves. Back

30. 6. What is the expected outcome of thrombolytic drug therapy? 1. Increased vascular permeability. 2. Vasoconstriction. 3. Dissolved emboli. 4. Prevention of hemorrhage Answer

31. 3. Thrombolytic therapy is use to dissolve emboli and reestablish cerebral perfusion. Back 32. 7. 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. Answer

33. * 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. Back

34. 8. Which client would the nurse identify as being most at risk for experiencing a CVA? 1. A 55year-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. Answer

35. 1. African Americans have twice the rate of CVAs as Caucasians; males are more likely to have strokes than females except in advanced years. Back

36. 9. 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. Answer

37. 3. Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a rupture blood vessel in the cranium. Back

38. 10. 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 clients waist prior to ambulating. 2. The assistant places the client on the back with the clients head to the side. 3. The assistant places her hand under the clients right axilla to help him/her move up in bed. 4. The assistant praises the client for attempting to perform ADLs independently. Answer

39. 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.