Nursing 4 Exam III

A patient is admitted with uncontrolled atrial fibrillation. The patient’s medication history includes vitamin D supplements and calcium. What type of stroke is this patient at MOST risk for?

ischemic embolism

ischemic stroke

hemorrhagic stroke

thrombotic stroke

embolic stroke

originates in the heart

intracerebral hemorrhage

subarachnoid hemorrhagic stroke

signs-worst headache, worsening neuro assessment

CT-ruptured aneurysm

treatment- aneurysm coiling, amlodipine

-will remain in the ICU after treatment since they are at risk for vasospasm(a narrowing of the arteries, delayed prolonged cerebral ischemia)

pripoirity intevrntion- ABC’s

The nurse is caring for a client recently admitted with a left middle cerebral artery stroke. Which of the following assessment findings would the nurse expect for this client?

Right sided numbness and tingling

dysarthria- slurred speech

right side hemiparesis

middle cerebral artery stroke (MCA)

face/arm weakness; speech chnages or neglect

ACA

leg-predominsny weakness

postier cirulcations

vision, balancem and crianal nerve changes

deficits often occur opposite the brain

nystagmus

rapid involuntary eye moevment

agnosia

inabaility to recognize familiar objects

hemianopia

partial loss of vision field

A stroke alert has been initiated for Mrs. Johnson. Which of the following clinical studies does the nurse anticipate first?

non contrast CT scan

-cna rule out hemorrhagic stroke to further guide treatmentn

what should be the first action after finding out a stroke isnt hemorrhagic

administer alteplase

-check last known well(within 4.5 hours)

-check bp

Alteplase is administered, and Mrs. Johnson is closely monitored per protocol in the ICU.

Six hours later, the nurse is preparing to administer medications to Mrs. Johnson. Which of the following medications should the nurse question?

heparin

-hold anticoagulants and anitplatlets for 24 hours afterwards

BEFAST for stroke

B- balance (loss of balance)

E- eyes (vision loss)

F-face (facial droop)

A-arm (one arm weakness)

S-speech (slurred speech)

T-time (when did it start, call 911 right away)

ABCS in stroke patients for maintaining helathy lifestyle

A- aspirin

B- blood pressure control

C-cholesterol managment

S- smoking cessation(it can cause vasoconstriction and plaque buildup, atherosclerosis)