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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
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 2 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 3 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 4 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.)
Question 5 of 5
Stroke after a major ischemic stroke, a possible complication is cerebral edema. Nursing care during the immediate recovery period from an ischemic stroke should include which of the following?
Correct Answer: A
Rationale: Positioning to avoid hypoxia reduces ICP in ischemic stroke recovery. High PaCO2 and early mobilization increase ICP; hypertonic saline is for hyponatremia.