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Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 67 : Management of Patients with Cerebrovascular Disorders Questions
Question 1 of 5
A nurse in the ICU is providing care for a patient who has been admitted with a hemorrhagic stroke. The nurse is performing frequent neurologic assessments and observes that the patient is becoming progressively more drowsy over the course of the day. What is the nurses best response to this assessment finding?
Correct Answer: D
Rationale: Increasing drowsiness indicates possible deterioration in hemorrhagic stroke, requiring immediate physician notification. It is not expected or due to metabolism, and stimulation is contraindicated.
Question 2 of 5
Following diagnostic testing, a patient has been admitted to the ICU and placed on cerebral aneurysm precautions. What nursing action should be included in patients plan of care?
Correct Answer: A
Rationale: Close supervision of ADLs prevents exertion that could elevate BP in aneurysm precautions. Ambulation and dietary restrictions are not indicated, and some ADLs may be allowed.
Question 3 of 5
A preceptor is discussing stroke with a new nurse on the unit. The preceptor would tell the new nurse which cardiac dysrhythmia is associated with cardiogenic embolic strokes?
Correct Answer: B
Rationale: Atrial fibrillation is strongly linked to cardiogenic embolic strokes due to thrombus formation. Other dysrhythmias are less associated.
Question 4 of 5
The pathophysiology of an ischemic stroke involves the ischemic cascade, which includes the following steps: 1. Change in pH 2. Blood flow decreases 3. A switch to anaerobic respiration 4. Membrane pumps fail 5. Cells cease to function 6. Lactic acid is generated. Put these steps in order in which they occur.
Correct Answer: C
Rationale: The ischemic cascade starts with decreased blood flow (2), then anaerobic respiration (3), lactic acid generation (6), pH change (1), membrane pump failure (4), and cell dysfunction (5).
Question 5 of 5
As a member of the stroke team, the nurse knows that thrombolytic therapy carries the potential for benefit and for harm. The nurse should be cognizant of what contraindications for thrombolytic therapy? Select all that apply.
Correct Answer: B,D,E
Rationale: Recent intracranial pathology, anticoagulation (INR >1.7), and symptom onset >3 hours are thrombolytic contraindications. INR above 1.0 is too low, and sudden onset is not a contraindication.)