Older Adult with Stroke HESI

Stroke is a major public health concern in this country. Because stroke causes major disability and death, it is critical to identify those at risk in order to implement prevention strategies by targeting modifiable risk factors. What risk factors in the client's history predispose him to stroke? (Select all that apply)

A. Male gender.

B. Heavy alcohol use.

C. History of transient ischemic attack (TIA).

D. Arthritis.

E. Sedentary lifestyle.

F. Obese and hypertensive.

A, B, C, E, & F

-Male gender.

Stroke is more common in men than in women. However, according to research articles more men may suffer strokes, but more women die or have more of a debility if they experience a stroke.

-Heavy alcohol use.

There is a known association with heavy alcohol use and strokes.

-History of transient ischemic attack (TIA).

Approximately 30% of individuals who experience a TIA have a stroke within 5 years.

-Sedentary lifestyle.

A sedentary lifestyle is associated with increased risk of a stroke.

-Obese and hypertensive.

Obesity is associated with hypertension, high blood glucose, and high lipid levels. All of these increase the risk of stroke if not controlled.

The client arrives to the emergency department (ED) via ambulance at approximately 0840. The paramedics give an SBAR report (situation, background, assessment, recommendation) to the ED medical staff. Based on the client's history, what is the most significant piece of information that warrants a more thorough investigation by the nurse?

A. Painful arthritis prevents the client from playing golf.

B. The client gained weight and he started smoking more frequently.

C. The client has a history of a TIA.

D. The client sometimes forgets to take his antihypertensive medication.

D. The client sometimes forgets to take his antihypertensive medication.

The nurse needs to question the client to determine when he last took the prescribed antihypertensive medications. Hypertension has a mechanical effect on the integrity of the blood vessels, leading to weakened vessel wall and/or formation of a thrombus, which can cause a stroke. The type of medication and the time taken will have implications for the prescribed plan of care.

The client is triaged and immediately assigned to the acute side of the ED. An additional IV line with an 18-gauge angiocath is started with an IV infusion of sodium chloride 0.9% at 80 mL/hr. Weight is obtained and a 12-lead EKG is performed. Within 10 minutes of being transported to the ED, the client experiences an episode of blindness in the right eye, loss of sensation in the right hand, and the inability to speak clearly. Which nursing action has highest priority?

A. Monitor blood pressure.

B. Check blood glucose level.

C. Assess pupillary reaction to light.

D. Administer acetylsalicylic acid as prescribed.

A. Monitor blood pressure.

Clients who have a stroke may have significant hypertension. The AHA recommends antihypertensive therapy only if blood pressure is higher than 220/120 mmHg because autoregulation of blood pressure at a higher level may help cerebral perfusion.

The stroke team is called to the ED. Based on presenting symptoms, the nurse suspects that the client has suffered left-sided brain damage. What observation would support this assessment? (Select all that apply)

A. Inability to understand speech and simple math questions.

B. Loss of the sense of time and a short attention span.

C. Slow, cautious behavior and anxiety.

D. Slurred speech and aphasia.

E. Problems with perception.

F. Right hemiplegia.

A, C, D, & F

-Inability to understand speech and simple math questions.

Impaired comprehension of language and math are indicative of left-sided brain damage.

-Slow, cautious behavior and anxiety.

These behaviors, as well as depression, are indicative of left-sided brain damage.

-Slurred speech and aphasia.

Impaired speech and aphasia are indicative of left-sided brain damage.

-Right hemiplegia.

Right hemiplegia (paralysis on one side of the body) or hemiparesis (weakness on one side of the body) indicates a stroke involving the left cerebral hemisphere because the motor nerve fibers cross in the medulla before entering the spinal cord and periphery.

The ED HCP utilizes a tool called the NIH Stroke Scale (NIHSS) created by the National Institute of Neurological Disorders and Stroke. The NIHSS is used to measure the severity of a stroke. The client's initial score in the ED prior to initiation of the rtPA is 20. In order for the ED HCP to begin the initiation of rtPA, the presence of an ischemic stroke needs to be confirmed by a noncontrast CT scan. Which nursing observation is consistent with ischemic rather than hemorrhagic stroke? (Select all that apply)

A. Pre-onset headache.

B. Rapid onset of severe symptoms.

C. Often occurs during or after sleep.

D. History of TIA.

E. No loss of consciousness in the first 24 hours.

F. Sudden onset with progression of symptoms over hours.

C, D, E, & F

-Often occurs during or after sleep.

This is in contrast to hemorrhagic stroke, which often has an onset after activity.

-History of TIA.

A TIA is considered a warning sign of ischemia stroke. Both TIA and stroke result from formation of a clot with vessel occlusion, but in stroke there is also infarction and cell death.

-No loss of consciousness in the first 24 hours.

Ischemic strokes are not associated with immediate loss of consciousness, unless it is a brainstem stroke or is accompanied by seizures and increased intracranial pressure. About 50% of persons with hemorrhagic stroke exhibit a decreased level of consciousness.

-Sudden onset with progression of symptoms over hours.

Sudden onset of symptoms is associated with ischemic stroke due to emboli. This occurrence is commonly associated with atrial fibrillation.

The client returns to the ED. Time is of the essence in stroke management. The healthcare team immediately seeks to determine the time of the ischemic event. According to his spouse, the client woke up at 0600 and asked for assistance getting to the bathroom. At that time, there were no signs of speaking difficulties or paralysis. The client's spouse states that stroke signs were evident two hours later, when he was found on the floor. The time is now 0920 and the nurse recognizes that the rtPA can restore blood flow if administered within 3 to 4½ hours following the ischemic event in clients with no recent bleeding events. The HCP adds orders to the electronic medical record (EMR). Based on the client's weight of 254 lb (115.21 kg), what is the total dose for the rtPA infusion? (Enter numerical value only. If rounding is necessary, round to the nearest tenth.)

103.7 mg

Based on the client's weight, the total dose for the rtPA infusion is 103.7 mg. The pharmacy sends an IVPB of 250 mL NS containing 150 mg of rtPA. How many milliliters of this fluid would be the total dose? (Enter numerical value only. If rounding is necessary, round to a whole number.)

173 mL

The client is to receive 10% of the total dose bolus over 20 minutes. What hourly rate will the nurse set the pump to deliver this dose over a 20-minute period? (Enter numerical value only. If rounding is necessary, round to the nearest whole number.)

52 mL/hr

The remainder of the rtPA dose is to infuse over an hour. What is the rate that the nurse will set the pump in order to deliver the remaining dose? (Enter numerical value only. If rounding is necessary, round to the nearest whole number.)

156 mL/hr

Client outcomes are often related to the delivery of emergency care. Which nursing intervention is appropriate to implement in the emergency care of the client?

A. An IV is initiated with dextrose 5% and water.

B. Allow small sips of water while the client remains alert.

C. Remove dentures and implement seizure precautions.

D. Turn the client's head to the nonaffected side and raise the head of the bed 90 degrees.

C. Remove dentures and implement seizure precautions.

Seizures occur in 5% to 7% of stroke patients in the first 24 hours.

On initial evaluation, the client has diminished gag and swallow reflexes, and his level of consciousness is decreasing. The nurse prioritizes airway management in the emergency phase and expects to implement which airway intervention?

A. Provide humidified air.

B. Prepare for intubation.

C. Prepare for tracheostomy.

D. Monitor respirations hourly.

B. Prepare for intubation.

Intubation and mechanical ventilation will be necessary because altered gag and swallow reflexes, as well as declining level of consciousness, make it difficult for the client to maintain an open airway.

Based on the client's confirmed diagnosis of ischemic stroke, the ED HCP orders a follow-up head CT scan with contrast and a head MRI with contrast STAT with an ED nurse in attendance. The nurse accompanies the client to the radiology department as he is transported via stretcher. The nurse brings an emergency intubation tray in the event the client requires intubation. The client is scheduled to have an open CT scan with contrast. What information should the nurse obtain prior to administering the intravenous contrast? (Select all that apply)

A. Whether the client has an allergy to iodine.

B. Whether the client has ever been allergic to peanuts.

C. Whether the client has any tattoos on his body.

D. Whether the client has a shellfish (crustacean) allergy.

E. Whether the client has any metal piercings or implants.

A & D

-Whether the client has an allergy to iodine.

The contrast that is used for CT scan procedures contains iodine.

-Whether the client has a shellfish (crustacean) allergy.

Studies have shown to be a correlation between shellfish allergies and an allergic reaction to the contrast used in CT scan procedures.

After the CT scan is completed, the client is transported to the MRI scan. His spouse accompanies him and the nurse for the MRI. What questions should the MRI technician ask of the client's spouse, to obtain information prior to the procedure? (Select all that apply)

A. Is the client allergic to iodine?

B. When was the last time the client ate or drank anything?

C. Is the client claustrophobic or afraid of closed-in, small places?

D. Does the client have any metal piercings or metal implants?

E. Did the client serve in the military? Does he have a history of shrapnel from a war injury?

C, D, & E

-Is the client claustrophobic or afraid of closed-in, small places?

Most MRIs are closed, requiring the client to be placed in a long, hollow cavity to conduct the exam. It is important for the technician to explain the procedure and prepare the client on what to expect from the MRI scan experience.

-Does the client have any metal piercings or metal implants?

The MRI is like a large magnet that uses magnetic field and radio waves to create an image of soft tissue and organs. Anything metal placed in the field while the machine is activated will be attracted to the magnetic field and could cause harm to the client.

-Did the client serve in the military? Does he have a history of shrapnel from a war injury?

The MRI is like a large magnet that uses magnetic field and radio waves to create an image of soft tissue and organs. Anything metal placed in the field while the machine is activated will be attracted to the magnetic field and could cause harm to the client.

Results of radiology imaging reconfirms that the client has suffered a left-sided ischemia stroke, which correlates with the presenting symptoms. The RN, LPN, and UAP are caring for the client during the acute phase while he is receiving the rtPA infusion. Which action can the RN delegate to the UAP? (Select all that apply)

A. Obtain vital signs.

B. Assist with positioning.

C. Assess swallowing ability.

D. Determine need for oxygen.

E. Measure intake and output (I&O).

A, B, & E

-Obtain vital signs.

The UAP can assist with activities of daily living (ADL), including taking vital signs, provided training has occurred.

-Assist with positioning.

The UAP can assist with activities of daily living (ADL), provided training has occurred.

-Measure intake and output (I&O).

The UAP can assist with activities of daily living (ADL), including measuring intake and output, provided training has occurred.

A bed in the neuro ICU becomes available and the client is transferred. The infusion of rtPA that was initiated in the ED has not completed infusing. Which prescribed medication should the nurse question for at least 24 hours after completion of the infusion of rtPA? (Select all that apply)

A. Heparin.

B. Warfarin.

C. Enoxaparin.

D. Antiarrhythmic.

E. Antithrombotic.

F. Acetylsalicylic acid.

A, B, C, E, & F

-Heparin.

Clients who have received fibrinolytic therapy for stroke should avoid any type of antiplatelet or antithrombotic for a period of at least 24 hours postinfusion due to increased risk of hemorrhaging.

-Warfarin.

Clients who have received fibrinolytic therapy for stroke should avoid any type of antiplatelet or antithrombotic for a period of at least 24 hours postinfusion due to increased risk of hemorrhaging.

-Enoxaparin.

Clients who have received fibrinolytic therapy for stroke should avoid any type of antiplatelet or antithrombotic for a period of at least 24 hours postinfusion due to increased risk of hemorrhaging.

-Antithrombotic.

Clients who have received fibrinolytic therapy for stroke should avoid any type of antiplatelet or antithrombotic for a period of at least 24 hours postinfusion due to increased risk of hemorrhaging.

-Acetylsalicylic acid.

Clients who have received fibrinolytic therapy for stroke should avoid any type of antiplatelet or antithrombotic for a period of at least 24 hours postinfusion due to increased risk of hemorrhaging.

The nurse develops a plan of care for the client. Priority is given to maintaining the airway. Which nursing problem best describes the nature of the client's respiratory problem?

A. Problems with gas exchange.

B. Airway clearance is not effective.

C. Breathing pattern is not effective.

D. Ventilation/perfusion ratio mismatches.

B. Airway clearance is not effective.

Decreased level of consciousness and impaired gag and swallow reflexes result in ineffective clearance of the airway.

During the 24 hours poststroke onset, the client experiences cerebral edema with a resulting decreased level of consciousness (LOC) and a temperature of 101.3° F (38.5° C). In addition to elevating the head of the bed and maintaining head alignment, what other measure is important to manage the increased intracranial pressure?

A. Maintain hips in 90° flexion.

B. Administer mannitol as ordered.

C. Avoid cooling blankets due to shivering effect.

D. Hold pain medication to avoid masking neurological signs.

B. Administer mannitol as ordered.

Diuretic drugs decrease intracranial pressure.

The client's spouse notices that the client's blood pressure is 180/100 mm Hg and questions the nurse about what treatment is being given to manage the high blood pressure. What is the best response for the nurse to provide to the client's spouse?

A. "Elevated blood pressure is not a concern with ischemic stroke."

B. "An antihypertensive medication has been administered. It needs time to take effect."

C. "Since your spouse's blood pressure has been consistently high, he can tolerate this elevation."

D. "High blood pressure is common after a stroke. It's the body's way of assuring a sufficient flow of blood to the brain."

D. "High blood pressure is common after a stroke. It's the body's way of assuring a sufficient flow of blood to the brain."

The family should be reassured that BP is being carefully monitored. Medication will be given if the systolic pressure exceeds 185 mmHg.

The nurse explains to the client's spouse that his BP is being monitored very closely because he received the infusion of rtPA. Additionally, other medication has been ordered to treat any increase in blood pressure. After an infusion of rtPA, what is the primary reason for keeping the BP below 185/110 mmHg?

A. Seizures.

B. Hyperthermia.

C. Myocardial ischemia.

D. Cerebral hemorrhage.

D. Cerebral hemorrhage.

Clients receiving rtPA require careful monitoring for cerebral hemorrhage or other signs of bleeding. Antihypertensive medications are prescribed when BP is greater than 180/105 mmHg.

Surgery is planned for the client. The client's spouse is confused and concerned about the procedure. She asks the nurse for clarification of the surgeon's explanation. Which is an accurate explanation of the surgical procedure that the nurse can provide to the family?

A. The weakened artery will be surgically clipped.

B. A small metal coil will be inserted into the weakened artery to prevent further bleeding.

C. A tiny catheter will be inserted in the femoral artery and a retriever will enter the blocked artery to remove the clot.

D. There is a weak area of bulging in the artery that caused a hematoma. The surgical procedure will evacuate this hematoma.

C. A tiny catheter will be inserted in the femoral artery and a retriever will enter the blocked artery to remove the clot.

This describes the mechanical embolus removal in cerebral ischemia (MERCI) procedure that is indicated for persons with ischemic stroke.

The client's surgery is successful. The clot is removed and a stent is put in place to help maintain the open vessel. Following emergent care, the client is now stable. As part of the rehabilitation phase of recovery, an in-depth neurological assessment is high priority. In addition to a comprehensive physical assessment, the nurse recognizes the importance of guidelines of the NIHSS and continues assessing per the specified intervals. An orientee asks the neuro ICU nurse about the NIHSS. Which statement by the nurse is correct?

A. The client must be alert when the scale is administered.

B. The scale is a simple-to-use tool that nurses can administer.

C. The scale evaluates the impact of cerebral infarction on comprehensive neurological functioning.

D. Because of its comprehensiveness, use of the scale eliminates the need to perform an in-depth neurological assessment.

C. The scale evaluates the impact of cerebral infarction on comprehensive neurological functioning.

Visual, language, and motor abilities are assessed, in addition to level of consciousness.

The client exhibits a degree of dysphagia following his stroke and subsequent treatment. After he is stabilized, a speech pathologist conducts a swallow evaluation and determines that the client can begin oral feeding. The nurse prepares to give the client his first feeding. Which action is an appropriate intervention?

A. Elevate the head of the bed 45°.

B. Assess swallow ability with a teaspoon of pureed food.

C. Begin feeding with milk since it is dense in calories.

D. Determine if the client can swallow a small amount of crushed ice.

D. Determine if the client can swallow a small amount of crushed ice.

After elevating the bed 90° and assessing the gag reflex, swallowing ability is assessed with a small amount of crushed ice.

It is determined that the client is at risk for deep vein thrombosis (DVT) due to his immobility and loss of muscle tone. A low-molecular-weight heparin is ordered. The client receives enoxaparin subcutaneously (SQ) as a preventive measure for DVT. While on this therapy, the nurse should monitor which laboratory report?

A. Platelet count.

B. Prothrombin time (PT).

C. International normalization ratio (INR).

D. Activated partial thromboplastin time (aPTT).

C. International normalization ratio (INR).

Clients receiving enoxaparin should have routine monitoring of the INR.

An important cardiovascular concern is prevention of DVT. The client is particularly at risk for development of DVT in his weakened right lower extremity. The client has no mobility in the right leg. The nurse delegates care assignments to the unlicensed assistive personnel (UAP) to foster client mobility. Which is a responsibility of the nurse that cannot be delegated to the UAP?

A. Applying elastic compression hose on both legs.

B. Performing passive range-of-motion exercises on the right leg.

C. Measuring the calf and thigh, noting any swelling, warmth, or pain.

D. Positioning the lower legs on pillows using a footboard while the client is in bed.

C. Measuring the calf and thigh, noting any swelling, warmth, or pain.

These actions describe assessment. Assessment is the role of the nurse and cannot be delegated.

The nurse is concerned about preventing joint contractures in the rehabilitation phase of the client's care. The nurse realizes that the client's right side, the weaker side, needs special attention when positioning. The nurse positions the client in bed. Which is the correct positional intervention to support optimal musculoskeletal function?

A. Place a trochanter roll at the left hip to prevent hip abduction.

B. Apply positioning boots on the client to prevent foot drop.

C. Insert rolled wash cloths in the client's right hand to maintain thumb-finger opposition.

D. Position the lower legs below the hip and knee joints to promote circulation.

B. Apply positioning boots on the client to prevent foot drop.

Positioning boots help to prevent foot drop. Use of a footboard is controversial as it may increase spasticity and prolonged pressure can precipitate a pressure injury.

Due to loss of sensation, immobility, nutritional needs, and decreased circulation, the client is at risk for skin breakdown. The nurse develops a plan of care to prevent skin breakdown. The plan of care for the client to prevent skin breakdown should include which intervention? (Select all that apply)

A. Avoid massaging any areas of redness.

B. Apply heel protectors on the client's heels.

C. Turn the client side-to-side every 2 hours.

D. Place a pressure relieving mattress on the bed.

E. Allow the client to sit in the wheelchair for no more than 3 hours at a time.

A, B, & D

-Avoid massaging any areas of redness.

Prolonged redness (greater than 15 minutes) indicates tissue damage. Massage increases the damage.

-Apply heel protectors on the client's heels.

Heel protectors help take the pressure off the bony prominent surface of the heel.

-Place a pressure relieving mattress on the bed.

Control of pressure is the most important intervention for prevention of skin breakdown.

The client is experiencing constipation. Due to swallowing difficulties, the client is ingesting approximately 1000 mL a day but is not eating fruits or vegetables. The nurse plans interventions to promote bowel motility and to relieve constipation. Which intervention is appropriate to include in the plan of care?

A. Request an order for a daily enema.

B. Maintain fluid intake at 1000 mL per day.

C. Administer prescribed stool softener daily.

D. Offer the client pureed fruits and vegetables.

C. Administer prescribed stool softener daily.

Stool softeners or fiber products are appropriate.

The client is experiencing urinary incontinence. In the initial phase of care, an indwelling urinary catheter is placed. The nurse updates the plan of care for urinary management to reflect the rehabilitation needs of the client. Which intervention is most appropriate?

A. Apply an external catheter.

B. Schedule toileting every 4 hours.

C. Reinsert the indwelling catheter every 8 hours.

D. Intermittent catheterization every 4 hours around the clock.

A. Apply an external catheter.

This is an appropriate measure for clients in the rehabilitation phase.

The client has been ambulating and sitting in a wheelchair. He is eating orally, but the nurse wishes to optimize his nutrition by encouraging a sufficient intake. The client has an intact gag reflex, but oral intake is suboptimal. Which strategy can be implemented to promote improved nutritional intake?

(Select all that apply)

A. Position the client upright in a chair for meals.

B. Have the client sit upright for one hour after meals.

C. Encourage the client to make selections from the menu.

D. Offer six smaller meals instead of three large meals per day.

E. Ask the client's spouse for a list of the his favorite healthy choice foods.

F. Request that the UAP open all containers and assist the client as needed.

A, C, D, E, & F

-Position the client upright in a chair for meals.

A 90° sitting position is ideal for meals. This upright position also allows gravity to help swallow effectively. The client can be placed in high Fowler position, but it is preferable to have him sit in a chair if he is able.

-Encourage the client to make selections from the menu.

Allowing the client to select his menu choices may help increase his consumption.

-Offer six smaller meals instead of three large meals per day.

It may be easier for the client to handle smaller meals at first, then progress up to three larger meals each day.

-Ask the client's spouse for a list of the his favorite healthy choice foods.

Including his spouse into his plan of care and assessing what foods he likes may help to make healthy choices of those foods and increase his appetite.

-Request that the UAP open all containers and assist the client as needed.

The client may have difficulty opening containers due to hemiplegia. The UAP can do this and assist the client in eating his meals as needed.

The nurse wants to determine if the client is ready to transfer from the bed to the chair. Which action indicates readiness?

A. Transient postural hypotension is evident upon sitting.

B. The client is able to securely grasp the arm of the chair.

C. The client is able to use his legs to push against the nurse's hands.

D. The client corrects his own posture when sitting at the edge of the bed.

D. The client corrects his own posture when sitting at the edge of the bed.

Autocorrecting posture is an indication of the balance that is needed for transfer.