While receiving thrombolytic therapy, the patient becomes sleepier. What is the nurse's first priority?
a. Stop the infusion if it is still hanging, and notify the
MD
b. Prepare for a stat Head CT
c. Perform a
full NIHSS
d. Administer Labetalol
A patient with an acute ischemic stroke is admitted from the emergency department to the ICU. The patient is difficult to arouse and not following commands. The nurse recognizes that a priority nursing action during the first 24 hours is:
a. Frequent neuro checks
b. Keeping the head of the bed elevated
c. Frequent
turning and positioning
d. Strict Intake and output
Dysphagia increases the risk of mortality in the stroke patient due to:
a. Gastroesophageal reflux
b. Malnutrition
c. Paralytic
ileus
d. Aspiration Pneumonia
Which of the following has the most significant impact on acute stroke patient outcomes?
a. Risk factor education
b. EMS communication plans
c. Reduction in door to needle times
d. Early
lipid screening
A 65-year-old presents to the emergency department (ED) with left side Facial Droop, dysarthria, and left sided weakness. According to the neighbor the patient was seen normal six hours prior to that arrival. The patient has a NIHSS of 8. The CT scan of the head is negative for bleeding and the labs are all WNL. The nurse should prepare the patient for:
a. Thrombolytic therapy administration
b. Immediate EEG
c.
Transfer to ICU to be monitored
d. Possible interventional procedure
In the early stages of ischemic stroke, the penumbral tissue is functionally silent yet metabolically active.
True
False
Lacunar strokes are small vessel strokes, and they are characterized by <15 mm infarct. What percent of Ischemic strokes are Lacunar or Small vessel?
a. 10%
b. 15%
c. 25%
d. 60%
The nurse is working with a patient who has just had an ischemic stroke. Patient is a smoker and does have hypertension. Patient has not taken his meds lately as he states he is feeling fine. Family is visiting and the nurse would like to begin education with the patient and family regarding risk factors for stroke. Which statement represents individualized education for this patient?
a. The nurse provided the patient with smoking cessation education
with the Georgia help line number.
b. The nurse discussed
importance of medication compliance especially regarding BP
medication, antiplatelet and Cholesterol lowering medications.
c.
The nurse reviewed patients’ individual medications including the next
doses due.
d. All the Above
A watershed infarct typically refers to a:
a. Stroke between two adjacent cerebral arteries
b. Hemorrhagic transformation
c. Stroke with associated
hydrocephalus
d. Hemorrhage in the pons
Which of the following is the most significant risk factor for stroke?
a. Smoking
b. Hypertension
c. Family
History
d. Diabetes
Which assessment findings are most consistent with alterations in the posterior cerebral circulation?
a. Right Hemiplegia and aphasia
b. Headache and
photophobia
c. Dizzy plus Diplopia
d.
Left hemiparesis and neglect
A 30-year-old patient came into the Emergency department and has been worked up as a stroke when it was determined the patient had a vertebral artery dissection. When the patient asks you “How did this happen?” what is your best response to the patient?
a. Sleep apnea
b. Trauma to the vessel wall
c. Uncontrolled hypertension
d. Uncontrolled blood glucose
A man arrives to the emergency department with his wife who had a sudden onset of slurred speech, right facial droop, and right sided weakness. When asked when this began the husband states about 30 minutes ago. Patient BP is 230/125 mm hg, blood glucose is 380 mg/ld. Her medical history includes an acute stroke which happened 2 months ago and hypertension. What is the first treatment the nurse would expect to provide.
a. Obtain weight and prepare to administer thrombolytic
b. Establish confirmation of Last known well time and
Prepare patient for CT
c. Contact the prior
neurologist to review prior stroke care
d. Evaluate compliance
with her current meds so you can treat blood sugar and BP
A patient presents to the Emergency Department with the “worst headache of their life”, nuchal rigidity, and photophobia. The non-contrast head CT is negative. What next test should the nurse prepare the patient for?
a. MRI of the Brain
b. Chest XRAY
c. CT perfusion scan
d. Lumbar puncture
Which of the following scale is a predictor of the 2-day risk of stroke after TIA?
a. CHADS2
b. NIHSS
c. Hunt and Hess
d. ABCD2
Oral contraceptives may increase the risk of stroke in women who:
a. Take combined progesterone and estrogen
b. Smoke
cigarettes
c. Have never been pregnant or given
birth
d. Live at high altitudes
Stroke risk is doubled by coronary artery disease and:
a. Heart failure
b. Smoking
c. Patent foramen ovale
d. Peripheral
vascular disease
In acute rehab a patient has expressed concerns about when he can have sexual relations with his wife after discharge. What would be the most appropriate nursing action?
a. Explain that it is an inappropriate topic to discuss, and she will
send in a male caregiver to discuss with him
b. Ask open ended questions to further evaluate the patients concerns
c. Explain to the patient sexual function should be fine and not
an issue after discharge
d. Let patient know he must not worry
about such things at this time in his recovery
Prenotification call by EMS was completed and the information was given that the patient had a new onset of dizziness which started 1 hour ago. Patient is also hypertensive, current blood pressure is 210/120, and Blood glucose is 90. The patient is in route and should arrive within 5 minutes. The ED charge nurse hangs up and prepares team for patient ED arrival. Upon arrival it will be important to complete which tasks to rule out a posterior stroke prior to EMS leaving facility?
a. Confirm time of Last known well by clock time not 1 hour
ago
b. Confirm the story and stroke scale from EMS when MD is
present so questions can be answered
c. Get patient family
contact number in case consent is needed for advanced therapy
d. All the above
BE FAST is now being used for stroke education in our community to assist with signs and symptoms of stroke. The BE in the acronym stands for what?
a. Behavior, Energy
b. Balance, Eyes
c. Boots, Earrings
d. Breathing, Emergent