MSN Exam for Stroke or Cerebro Vascular Accident (CVA)

EXPLANATION

 

✔Correct answer:

Having obesity. Obesity is a well-documented risk factor for cerebrovascular accidents (CVAs), also known as strokes. Excess body weight contributes to a variety of conditions that increase stroke risk, such as hypertension (high blood pressure), diabetes, dyslipidemia (abnormal lipid levels), and cardiovascular disease. These conditions can lead to the development of atherosclerosis (hardening and narrowing of the arteries), which can impede blood flow to the brain and result in a stroke.

Obesity can cause changes in metabolism and hemodynamics that increase the risk of vascular problems. For example, excess fat tissue requires an increased blood supply, leading to higher blood pressure. Additionally, obesity is associated with insulin resistance and higher blood sugar levels, increasing the risk of diabetes, which further elevates stroke risk.

Think of the blood vessels as highways. If there are more cars (fat cells), the traffic (blood flow) is slower and more likely to cause accidents (strokes) due to congestion and blockages (atherosclerosis).

To manage and reduce stroke risk in obese patients, interventions may include:

• Encouraging weight loss through a balanced diet and regular physical activity.
• Monitoring blood pressure, glucose levels, and lipid profiles regularly.
• Educating patients about the importance of lifestyle changes to reduce risk factors associated with obesity.
• Collaborating with dietitians, physical therapists, and other healthcare professionals to develop a comprehensive care plan.

 

✘Incorrect answer options:

Being of Caucasian race. While race can influence the risk of certain diseases, being Caucasian is not specifically a major risk factor for stroke. African Americans and Hispanics have higher stroke risks compared to Caucasians.

Being of female sex. Sex can influence stroke risk, and women do have unique risk factors (such as pregnancy, birth control use, and post-menopausal hormone therapy). However, sex alone is not as significant a risk factor as obesity.

Having bronchial asthma. Asthma is primarily a respiratory condition and is not directly associated with an increased risk of stroke. While chronic inflammation and some asthma medications might have indirect effects on cardiovascular health, they are not considered major stroke risk factors.

 

References

• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.

EXPLANATION

 

✔Correct answer:

Blood pressure. After thrombolytic therapy for an ischemic stroke, it is crucial to closely monitor and control blood pressure. Elevated blood pressure can increase the risk of hemorrhagic transformation, where the clot-dissolving medication can lead to bleeding in the brain. Conversely, excessively low blood pressure can compromise cerebral perfusion, potentially leading to further ischemic damage. Therefore, maintaining blood pressure within a target range is essential to balance the risk of bleeding with adequate brain perfusion.

Thrombolytic therapy, such as tissue plasminogen activator (tPA), works by dissolving the blood clot causing the stroke. However, the use of tPA increases the risk of bleeding, especially if blood pressure is not well-controlled. Elevated blood pressure can exacerbate this risk, while low blood pressure can lead to insufficient blood flow to the brain, worsening the ischemic damage.

Think of blood vessels as garden hoses. If the pressure is too high, the hoses can burst (leading to bleeding). If the pressure is too low, the plants won’t get enough water (leading to poor perfusion). Similarly, controlling blood pressure is crucial to avoid bleeding and ensure adequate blood flow to the brain.

Nurse Adams should implement measures to closely monitor and manage Mrs. Lewis’s blood pressure during the first 24 hours post-thrombolytic therapy.

• Monitor blood pressure frequently, typically every 15 minutes for the first 2 hours, then every 30 minutes for the next 6 hours, and every hour thereafter, as per hospital protocol.
• Administer antihypertensive medications as prescribed to maintain blood pressure within the target range.
• Assess for signs and symptoms of intracranial hemorrhage, such as sudden headache, nausea, vomiting, decreased level of consciousness, and new neurological deficits.
• Ensure IV access is maintained for rapid administration of medications if needed.
• Coordinate with the healthcare team to adjust the treatment plan based on blood pressure readings and clinical status.

 

✘Incorrect answer options:

Pulse. While monitoring heart rate is important, it is not the primary focus immediately post-thrombolytic therapy. Blood pressure control is more critical to prevent complications associated with bleeding and perfusion.

Respirations. Monitoring respiratory rate and ensuring adequate oxygenation are important, but they are not the primary concern related to the risks of thrombolytic therapy. Blood pressure control is paramount to prevent hemorrhage.

Temperature. Maintaining a normal temperature is important as hyperthermia can worsen neurological outcomes, but it is not the immediate priority compared to controlling blood pressure in the context of thrombolytic therapy.

 

References

• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.

EXPLANATION

 

✔Correct answer:

Regulating body temperature. The hypothalamus is a critical part of the brain involved in maintaining homeostasis, including the regulation of body temperature. When the hypothalamus is affected by a cerebrovascular accident (CVA), the body's ability to regulate temperature can be impaired, leading to problems such as hyperthermia or hypothermia.

The hypothalamus acts as the body's thermostat, sensing changes in body temperature and initiating responses to adjust and maintain a stable internal environment. It controls mechanisms such as sweating, shivering, and adjusting blood flow to the skin. Damage to the hypothalamus from a stroke can disrupt these processes, making it difficult for the body to maintain a consistent temperature.

Think of the hypothalamus as a thermostat in a house. If the thermostat is damaged, it can no longer correctly regulate the heating and cooling systems, leading to temperatures that are too high or too low, similar to how the body’s temperature regulation is affected when the hypothalamus is damaged.

Nurse Anna should closely monitor Mr. Wilson’s body temperature and take measures to maintain it within a normal range.

• Regularly check Mr. Wilson's body temperature and observe for signs of hyperthermia (e.g., sweating, flushed skin) or hypothermia (e.g., shivering, cold extremities).
• Implement temperature control measures as needed, such as providing blankets for warmth or cooling measures like fans and ice packs.
• Educate the patient and family about the importance of maintaining a stable room temperature and avoiding extreme temperatures.
• Ensure adequate hydration, as fluid balance also affects temperature regulation.
• Coordinate with the healthcare team to adjust the environment and medications that may impact temperature regulation.

 

✘Incorrect answer options:

Maintaining balance and equilibrium. Balance and equilibrium are primarily controlled by the cerebellum and the vestibular system, not the hypothalamus. Damage to these areas would result in balance issues, but the hypothalamus is not directly involved in these functions.

Visual acuity. Visual acuity is managed by the occipital lobe of the brain, where the primary visual cortex is located, as well as the optic pathways. The hypothalamus does not play a direct role in vision, so damage to the hypothalamus would not typically affect visual acuity.

Cognitive functions such as thinking and reasoning. Cognitive functions such as thinking and reasoning are primarily governed by the cerebral cortex, particularly the frontal lobes. While the hypothalamus is involved in many autonomic and endocrine functions, it is not directly responsible for higher cognitive functions.

 

References

• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.

EXPLANATION

 

✔Correct answer:

Observing the pupil size and papillary response.  In the acute phase of a thrombotic stroke, the priority nursing assessment should be to observe the pupil size and papillary response. Changes in pupil size and reactivity can indicate increased intracranial pressure (ICP), worsening neurological status, or brain herniation, which are critical conditions that require immediate medical intervention. Monitoring these signs helps in early detection of complications and guides prompt treatment to prevent further brain injury.

A thrombotic stroke occurs when a blood clot forms in one of the arteries supplying blood to the brain, leading to reduced blood flow and oxygen to brain tissue. This can result in ischemia and neuronal damage. Changes in intracranial pressure can affect the cranial nerves, particularly the optic and oculomotor nerves, which control pupil size and reactivity. Thus, assessing these parameters provides vital information about the patient’s neurological status.

Think of pupil assessment as checking the warning lights on a car dashboard. If a warning light indicates an issue, it alerts you to check the engine. Similarly, changes in pupil response alert healthcare providers to potential neurological issues that need immediate attention.

Nurse Wilson should incorporate regular and frequent assessments of Mr. Hartman’s neurological status, focusing on pupil size and reactivity, alongside other vital signs.

• Assess the patient's pupils for size, shape, equality, and reaction to light. Document findings and report any abnormalities immediately.
• Monitor the patient’s level of consciousness and orientation, as changes may indicate worsening neurological status.
• Perform frequent neurological checks, including assessing motor function, strength, and sensory responses.
• Communicate any changes in neurological status promptly to the healthcare team for timely intervention.
• Maintain a quiet and safe environment to reduce stimuli that could increase intracranial pressure.

 

✘Incorrect answer options:

The patient's cholesterol level. While cholesterol levels are important for long-term management and prevention of further strokes, they are not the immediate priority in the acute phase of stroke care.

Monitoring the vowel sounds. Monitoring speech patterns and articulation (not "vowel sounds") can provide information about the location and extent of the stroke, but it is not as critical as monitoring neurological status via pupil assessment in the first 24 hours.

Scheduling an echocardiogram. An echocardiogram may be useful for identifying cardiac sources of emboli or other heart-related issues, but it is not the priority in the immediate assessment and management of an acute stroke.

 

References

• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.

EXPLANATION

 

✔Correct answer:

Arrange for an immediate computer tomography (CT) scan of the head. The priority nursing intervention for Mr. Walker, who is presenting with symptoms of a possible stroke (numbness and weakness in his left arm and slurred speech), is to arrange for an immediate CT scan of the head. This diagnostic imaging is crucial for determining whether the stroke is ischemic or hemorrhagic. Prompt diagnosis is essential for deciding the appropriate treatment plan, particularly if thrombolytic therapy (such as rt-PA) is being considered.

A stroke occurs when there is a disruption of blood flow to the brain, which can be due to a blockage (ischemic stroke) or bleeding (hemorrhagic stroke). An immediate CT scan helps differentiate between these two types, which is vital because the treatments differ significantly. Thrombolytic therapy, which can dissolve blood clots, is only appropriate for ischemic strokes and must be administered within a specific time window from the onset of symptoms.

If a pipe bursts in your house, you need to know if it's due to a clog or a break before you decide whether to use a plunger or call a plumber. Similarly, you need to identify the type of stroke before starting treatment.

Ensuring a rapid and accurate diagnosis is the top priority to initiate the correct treatment and improve the patient's outcome.

• Arrange for an immediate CT scan of the head to identify the type of stroke.
• Monitor the patient’s vital signs and neurological status closely.
• Prepare for potential treatments based on the CT scan results, such as thrombolytic therapy for ischemic stroke.
• Provide reassurance and communicate clearly with the patient and family about the steps being taken.
• Coordinate with the stroke team or neurologist for further evaluation and management.

 

✘Incorrect answer options:

Prepare to administer a recombinant tissue plasminogen activator (rt-PA). While rt-PA can be a critical treatment for ischemic stroke, it should not be prepared or administered until a CT scan confirms the stroke is not hemorrhagic. Administering rt-PA in the case of a hemorrhagic stroke could be life-threatening.

Discuss the factors that might have precipitated the symptoms. Understanding the factors leading to the stroke is important but not an immediate priority. Immediate diagnostic imaging to confirm the stroke type is the priority to initiate timely treatment.

Call the speech pathologist for an urgent consultation. A speech pathologist will be important in the rehabilitation phase for managing slurred speech and communication issues. However, the immediate priority is to diagnose and treat the stroke.

 

References

• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.

EXPLANATION

 

✔Correct answer:

An African American male, aged 55. Among the listed patients, the African American male, aged 55, has the highest risk for experiencing a cerebrovascular accident (CVA). African Americans have a higher prevalence of hypertension, diabetes, and other risk factors that contribute significantly to the risk of stroke. Furthermore, males generally have a higher risk of stroke compared to females, and age 55 is within the range where stroke risk begins to increase significantly.

The risk of stroke is influenced by multiple factors, including race, age, sex, and underlying health conditions. African Americans have nearly twice the risk of first-ever strokes compared to Caucasians, partly due to higher rates of hypertension, diabetes, and obesity. Hypertension, in particular, is a leading cause of stroke, and controlling blood pressure is crucial in reducing stroke risk.

Imagine stroke risk as climbing a hill. For some individuals, the hill is steeper due to their race, age, and health conditions. African American males have a steeper hill to climb because of higher rates of hypertension and other risk factors.

Nurse Carter should focus on identifying and managing modifiable risk factors in high-risk patients, including controlling blood pressure, managing diabetes, encouraging a healthy diet, promoting physical activity, and addressing smoking cessation.

• Regularly monitor blood pressure and blood glucose levels.
• Educate the patient about the importance of a healthy lifestyle, including a balanced diet and regular exercise.
• Encourage adherence to prescribed medications for hypertension, diabetes, and other relevant conditions.
• Provide resources and support for smoking cessation if applicable.
• Schedule regular follow-up appointments to monitor the patient’s health status and adjust the care plan as needed.

 

✘Incorrect answer options:

A Japanese female, aged 84. While age is a significant risk factor for stroke, Japanese individuals typically have lower rates of stroke compared to African Americans. Additionally, females have a slightly lower risk of stroke compared to males of the same age.

A Caucasian male, aged 67. Although age and male sex are risk factors, the stroke risk in Caucasians is lower compared to African Americans. This makes the African American male a higher risk individual despite the Caucasian male's advanced age.

A pregnant female, aged 39. Pregnancy can increase the risk of stroke due to hypercoagulability and other physiological changes, but this risk is generally lower compared to the chronic risk factors present in the African American male. Additionally, age 39 is relatively younger compared to the other options, reducing overall risk.

 

References

• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.

EXPLANATION

 

✔Correct answer:

Holding the cane in her left hand, Ms. Kelly moves the cane forward first, then her right leg, followed by her left leg.  The correct use of a cane for someone with severe right-sided weakness involves holding the cane on the stronger, unaffected side (left hand in this case). Ms. Kelly should move the cane forward first to provide support, then move her weaker right leg, followed by her stronger left leg to maintain balance and stability.

Using a cane correctly helps redistribute weight away from the weaker side and provides additional support, improving balance and reducing the risk of falls. By moving the cane and the weaker leg in a coordinated manner, the patient ensures that the cane supports the body during the most unstable phase of the gait cycle.

Think of the cane as a third leg that supports you while you move the weaker leg. Holding it on the stronger side ensures that the support is available when your weak leg needs it the most.

Nurses should ensure patients are taught and supervised in the correct use of assistive devices like canes to promote safe ambulation and prevent falls.

• Ensure the patient holds the cane on the unaffected (stronger) side.
• Instruct the patient to move the cane forward first, which helps stabilize the body.
• Teach the patient to move the weaker leg forward next, using the cane for support.
• Encourage the patient to follow with the stronger leg, ensuring a stable and balanced gait.
• Provide ongoing supervision and adjust the cane height if necessary to ensure proper posture and support.

 

✘Incorrect answer options:

Holding the cane in her right hand, Ms. Kelly moves the cane forward first, then her left leg, followed by her right leg. Holding the cane on the weaker side (right hand in this case) does not provide optimal support and balance, increasing the risk of falls.

Holding the cane in her right hand, Ms. Kelly moves the cane and her right leg forward together, then moves her left leg forward. This method does not provide adequate support as the cane should be on the stronger side to offer the necessary stability when moving the weaker leg.

Holding the cane in her left hand, Ms. Kelly moves the cane and her left leg forward together, then moves her right leg forward. Moving the cane and the stronger leg together defeats the purpose of using the cane for support. The cane should be moved first, followed by the weaker leg, to maximize stability.

 

References

• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.

EXPLANATION

 

✔Correct answer:

Position Mr. Anderson's left side closest to the bed. When transferring a patient who has experienced a right-sided cerebrovascular accident (CVA) and has right-sided weakness, it is safest to position the stronger side (in this case, the left side) closest to the bed. This allows the patient to use their stronger side to assist in the transfer, providing better stability and reducing the risk of falls or injury.

After a CVA affecting the right side, the left side of the body is typically stronger and more coordinated. Positioning the left side closest to the bed leverages the patient's remaining strength and functionality, facilitating a safer and smoother transfer.

Imagine trying to climb out of a pool. You would want to use the side of your body with more strength to push yourself up to ensure you don’t slip back into the water.

Ensuring safe transfers is critical to prevent falls and injuries in patients with hemiparesis following a CVA. Proper positioning and technique are essential components of nursing care.

• Position the wheelchair at an angle to the bed, with the left side of Mr. Anderson’s body closest to the bed.
• Lock the wheelchair brakes to prevent movement during the transfer.
• Instruct Mr. Anderson to use his left arm to push off the wheelchair and assist in the transfer.
• Support Mr. Anderson’s right side during the transfer to provide stability and prevent falls.
• Ensure the bed is at an appropriate height to facilitate the transfer without excessive strain.

 

✘Incorrect answer options:

Position Mr. Anderson's right side closest to the bed. Positioning the weaker right side closest to the bed does not leverage the patient's stronger side, making the transfer more difficult and increasing the risk of falls or injury.

Position Mr. Anderson facing away from the bed. Positioning the patient facing away from the bed complicates the transfer process, making it awkward and unsafe. The patient needs to face the bed to see and properly execute the movements required for a safe transfer.

Position Mr. Anderson at a 45-degree angle to the bed. While positioning the wheelchair at an angle to the bed is a good practice, specifying a 45-degree angle alone without considering which side is closer to the bed does not address the need to use the stronger side for the transfer. The critical factor is ensuring the stronger left side is closest to the bed.

 

References

• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.

EXPLANATION

 

✔Correct answer:

Shift weight away from the affected side. When using a cane, holding it on the unaffected (stronger) side helps to shift weight away from the affected (weaker) side. This provides better balance and support, as the unaffected side is stronger and can bear more weight, thereby reducing the load on the weaker side. This method helps to maintain stability during ambulation and reduces the risk of falls or further injury.

After a cerebrovascular accident (CVA), also known as a stroke, patients may experience weakness or paralysis on one side of the body. Using a cane on the stronger side allows the patient to compensate for this weakness by providing a point of stability and leverage, which aids in safer and more effective movement.

Imagine walking on a slippery path with one foot being less steady. Using a stick (cane) on the side where you have more control helps you balance better and prevent slipping, just as using a cane on the stronger side helps balance and support the weaker side.

Proper training in the use of assistive devices like canes is crucial for stroke patients to ensure safe ambulation and prevent falls.

• Educate the patient on the correct use of the cane, including holding it on the unaffected side.
• Demonstrate the proper technique and supervise initial use to ensure the patient is using the cane correctly.
• Provide support and encouragement, reinforcing the importance of using the cane to shift weight away from the weaker side.
• Assess the patient’s home environment for safety and suggest modifications if necessary to facilitate safe ambulation.
• Monitor the patient’s progress and adjust the cane’s height or provide additional training as needed.

 

✘Incorrect answer options:

Avoid leaning to one side. While holding the cane on the unaffected side does help to maintain a more balanced posture, the primary reason is to shift weight away from the affected side. Simply avoiding leaning does not address the core issue of weight distribution and support.

Keep a consistent stride length. Although using a cane correctly can contribute to a more consistent stride length, this is not the primary reason for holding the cane on the unaffected side. The main goal is to provide support and balance.

Reduce the risk of edema. The use of a cane does not directly impact the risk of edema. Edema management typically involves other interventions such as elevation, compression, and monitoring fluid intake and output.

 

References

• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.

EXPLANATION

 

✔Correct answer:

Global aphasia. Global aphasia is characterized by severe impairment in both the comprehension and production of speech. This type of aphasia typically results from extensive damage to the brain's language areas, including both Broca's area (responsible for speech production) and Wernicke's area (responsible for speech comprehension). As Ms. Taylor is unable to comprehend speech and unable to speak, she exhibits the symptoms of global aphasia.

Global aphasia usually occurs after a large cerebrovascular accident (CVA) or stroke that affects the dominant hemisphere of the brain (typically the left hemisphere for most right-handed individuals). This extensive damage disrupts the pathways required for both understanding and producing language, leading to a severe impairment of all aspects of language function.

Imagine a computer with both its keyboard and screen damaged. Just as you cannot input data (speak) or read information (comprehend) on such a computer, a person with global aphasia cannot produce or understand language.

Caring for a patient with global aphasia involves a multidisciplinary approach to support communication and overall health.

• Use non-verbal communication methods such as gestures, pictures, and communication boards to aid understanding.
• Ensure a quiet environment to minimize distractions and enhance the patient's ability to focus on non-verbal cues.
• Engage speech and language therapists to develop individualized communication strategies and therapies.
• Involve family members in learning and using communication techniques to support the patient.
• Monitor the patient for signs of frustration or distress and provide emotional support and reassurance.

 

✘Incorrect answer options:

Receptive aphasia. Also known as Wernicke's aphasia, receptive aphasia is characterized by difficulty understanding spoken or written language, but speech production is typically fluent, though often nonsensical. Ms. Taylor's inability to speak suggests a broader impairment.

Expressive aphasia. Also known as Broca's aphasia, expressive aphasia involves difficulty in speech production but typically with relatively preserved comprehension. Patients can understand language better than they can express it, which does not match Ms. Taylor's inability to comprehend speech.

Conduction aphasia. Conduction aphasia involves intact comprehension and relatively fluent speech, but with difficulty repeating words or sentences and frequent phonemic errors. This does not align with Ms. Taylor's symptoms of both impaired comprehension and speech production.

 

References

• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.

EXPLANATION

 

✔Correct answer:

A blood pressure reading of 220/120 mm Hg. Hypertension (high blood pressure) is the most significant risk factor for hemorrhagic stroke. A blood pressure reading of 220/120 mm Hg indicates a hypertensive crisis, which significantly increases the risk of blood vessel rupture in the brain, leading to a hemorrhagic stroke. This type of stroke occurs when a weakened blood vessel ruptures and bleeds into the surrounding brain tissue.

Chronic hypertension causes damage to the blood vessel walls, making them more susceptible to rupture. When blood pressure is extremely high, the force exerted against the arterial walls can lead to a hemorrhage. This bleeding increases intracranial pressure and can cause significant damage to brain tissue.

Imagine a garden hose with very high water pressure. If the pressure continues to increase, the hose is likely to burst at its weakest point. Similarly, high blood pressure can cause a blood vessel in the brain to burst, leading to a hemorrhagic stroke.

Nurse Williams should focus on managing and monitoring blood pressure to reduce the risk of hemorrhagic stroke.

• Monitor blood pressure regularly and ensure it is managed within a safe range through medication and lifestyle changes.
• Educate the patient on the importance of adhering to antihypertensive medications.
• Encourage a healthy diet low in sodium, regular physical activity, and weight management to control blood pressure.
• Assess for signs and symptoms of a hypertensive crisis, such as severe headache, vision problems, chest pain, and shortness of breath.
• Implement emergency interventions if the patient presents with a hypertensive crisis, including IV antihypertensive medications and continuous monitoring.

 

✘Incorrect answer options:

A blood glucose level of 480 mg/dl. High blood glucose levels are a risk factor for ischemic stroke due to diabetes-related vascular damage, but they are not directly associated with an increased risk of hemorrhagic stroke.

A right-sided carotid artery bruit. A carotid artery bruit suggests turbulent blood flow due to atherosclerosis, which increases the risk of ischemic stroke rather than hemorrhagic stroke.

The presence of bronchogenic carcinoma. While certain cancers can increase the risk of stroke through hypercoagulability or metastatic spread, bronchogenic carcinoma is not specifically associated with an increased risk of hemorrhagic stroke.

 

References

• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.

EXPLANATION

 

✔Correct answer:

Determining the exact time the current stroke symptoms began. In the context of administering tissue plasminogen activator (t-PA) for an ischemic stroke, the most critical factor is the time window from the onset of stroke symptoms. t-PA is a thrombolytic medication that is highly effective at dissolving blood clots if administered within a specific time frame, typically within 4.5 hours from symptom onset. Determining the exact time the symptoms began is essential to ensure the treatment is safe and effective.

Ischemic strokes occur when a blood clot obstructs a blood vessel supplying blood to the brain, leading to a reduction in blood flow and oxygen to the affected area. t-PA works by breaking down the clot, restoring blood flow, and minimizing brain damage. However, if administered beyond the recommended time window, the risk of complications such as hemorrhage outweighs the benefits.

Imagine a fire that has just started; using water immediately can extinguish it and prevent damage. However, if you wait too long, the fire might spread too much, and using water could cause further complications. Similarly, t-PA must be used promptly to be effective and safe.

Nurse Simmons should prioritize confirming the exact time the stroke symptoms began to ensure the patient is within the treatment window for t-PA.

• Immediately ask the patient, family members, or witnesses about the exact time the stroke symptoms were first noticed.
• Document the time of symptom onset accurately in the patient’s medical record.
• Monitor the patient’s vital signs and neurological status closely before, during, and after t-PA administration.
• Prepare for potential complications, such as bleeding, and ensure that emergency equipment is readily available.
• Communicate with the stroke team or neurologist to coordinate care and follow protocols for t-PA administration.

 

✘Incorrect answer options:

Reviewing the patient's current medications. While it is important to review the patient's medications to check for contraindications to t-PA (e.g., anticoagulants), this is not the immediate priority compared to determining the time of symptom onset.

Conducting a comprehensive physical exam and history. A thorough physical exam and history are important, but in the emergency setting of an ischemic stroke, ensuring the patient is within the treatment window for t-PA takes precedence.

Checking for any upcoming surgical procedures. While it is important to consider surgical history and any planned procedures, this is secondary to confirming the eligibility for t-PA based on the time window of symptom onset.

 

References

• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.

EXPLANATION

 

✔Correct answer:

Dissolved emboli. The primary expected outcome of thrombolytic drug therapy is the dissolution of blood clots (emboli). Thrombolytic agents, such as tissue plasminogen activator (tPA), work by breaking down clots that obstruct blood flow in the blood vessels, thereby restoring circulation and minimizing tissue damage. In the context of an ischemic stroke, the goal is to dissolve the clot blocking blood flow to the brain as quickly as possible to prevent further ischemia and neurological damage.

Thrombolytic drugs activate the enzyme plasminogen to form plasmin, which digests fibrin, the primary protein component of blood clots. By breaking down the fibrin matrix, these drugs help to dissolve existing clots and restore normal blood flow. This process is crucial in treating conditions like ischemic stroke, where timely reperfusion of the affected brain area can significantly improve outcomes and reduce long-term disability.

Imagine a clogged drain in your sink. Using a drain cleaner to dissolve the blockage allows water to flow freely again. Similarly, thrombolytic drugs dissolve clots to restore blood flow in blocked vessels.

Nurse Lee should monitor Mr. Davis for signs of improved circulation and neurological function, as well as for potential complications associated with thrombolytic therapy.

• Monitor neurological status frequently to assess for improvements or changes in symptoms.
• Check for signs of bleeding, as thrombolytic therapy increases the risk of hemorrhage.
• Assess vital signs regularly, paying close attention to blood pressure and heart rate.
• Ensure intravenous access for administering medications and fluids as needed.
• Educate the patient and family about the purpose of thrombolytic therapy and the importance of early intervention in stroke management.

 

✘Incorrect answer options:

Increased vascular permeability. Thrombolytic drugs do not primarily aim to increase vascular permeability. Increased permeability can actually be a risk factor for bleeding, which is a potential complication of thrombolytic therapy, not its goal.

Vasoconstriction. Thrombolytic therapy does not aim to cause vasoconstriction. Instead, it focuses on dissolving clots to restore blood flow. Vasoconstriction would reduce blood flow, contrary to the therapy's purpose.

Prevention of hemorrhage. While minimizing the risk of hemorrhage is important in managing patients receiving thrombolytic therapy, the primary goal of these drugs is to dissolve clots. The prevention of hemorrhage is managed through careful monitoring and selection criteria to ensure appropriate use of thrombolytic agents.

 

References

• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.

EXPLANATION

 

✔Correct answer:

Contact the physician immediately. A severe headache in a patient with a diagnosed cerebral aneurysm is a medical emergency. This symptom could indicate that the aneurysm is leaking or has ruptured, which can lead to a subarachnoid hemorrhage, a life-threatening condition. Immediate medical intervention is critical to manage the situation, potentially involving diagnostic imaging, surgical intervention, and critical care support.

A cerebral aneurysm is a weakened area in the wall of a blood vessel in the brain that causes it to bulge or balloon out. If an aneurysm leaks or ruptures, it can cause bleeding into the space around the brain (subarachnoid hemorrhage), leading to increased intracranial pressure, brain damage, and potentially death if not treated promptly.

Imagine a balloon with a weak spot being slowly inflated. If the balloon suddenly bursts, the rapid release of air can cause significant disruption and damage. Similarly, if a cerebral aneurysm ruptures, the sudden release of blood into the brain can cause severe complications.

Nurses must act swiftly to ensure the patient receives immediate medical attention. They should also be prepared to monitor and manage the patient’s vital signs and symptoms until further help arrives.

• Contact the physician immediately to report the patient's symptoms and seek urgent intervention.
• Prepare the patient for potential diagnostic tests, such as a CT scan or MRI, to confirm the diagnosis.
• Ensure the patient is in a safe and comfortable position and closely monitor their vital signs.
• Administer prescribed medications or interventions as directed by the physician to manage symptoms and stabilize the patient.
• Provide emotional support and reassurance to the patient, explaining that help is on the way.

 

✘Incorrect answer options:

Stay with the patient for a few moments. While it is important to provide reassurance and monitor the patient, simply staying with the patient without taking further action delays critical intervention that could save the patient's life.

Provide the patient with an analgesic. Administering an analgesic may temporarily alleviate the headache, but it does not address the underlying potentially life-threatening cause. This could also delay diagnosis and appropriate treatment.

Notify the nurse manager. While informing the nurse manager may be necessary as part of the communication protocol, it is not the immediate priority. The primary action should be to contact the physician who can provide the necessary medical intervention.

 

References

• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.

EXPLANATION

 

✔Correct answer:

Encouraging weight-bearing exercises. To help prevent the development of diffuse osteoporosis, it is essential to engage in weight-bearing exercises. These exercises promote bone health by stimulating bone formation and slowing bone loss. Weight-bearing activities, such as walking, stair climbing, and resistance training, force the bones to work against gravity, which helps to maintain and increase bone density.

Osteoporosis is a condition characterized by weakened bones that are more susceptible to fractures. It occurs when bone resorption (breakdown) outpaces bone formation. Weight-bearing exercises promote bone remodeling and increase bone strength by applying mechanical stress to the bones, which stimulates the activity of osteoblasts (bone-building cells).

Imagine a tree that grows stronger when it sways in the wind. The movement forces the tree to develop a stronger trunk and roots. Similarly, weight-bearing exercises act like the wind, encouraging bones to become denser and stronger.

Nurses should develop a care plan that includes safe and appropriate weight-bearing exercises for patients recovering from a cerebrovascular accident.

• Assess the patient’s physical ability and limitations before recommending exercises.
• Encourage activities such as walking, standing exercises, and using resistance bands under supervision.
• Coordinate with physical therapists to develop a personalized exercise regimen.
• Monitor the patient’s response to exercises and adjust the plan as necessary.
• Educate the patient and family about the benefits of weight-bearing exercises for bone health.

 

✘Incorrect answer options:

Ensuring adequate protein intake. While adequate protein intake is important for overall health and muscle maintenance, it does not directly address bone density. Protein is crucial for muscle repair and immune function but does not have the same impact on bone strength as weight-bearing exercises.

Ensuring adequate vitamin intake. Adequate vitamin intake, particularly vitamin D and calcium, is important for bone health, but it is not sufficient alone to prevent osteoporosis. These nutrients support bone metabolism, but weight-bearing exercises are necessary to stimulate bone growth and maintain bone density.

Encouraging range-of-motion (ROM) exercises. Range-of-motion exercises are important for maintaining joint flexibility and preventing contractures, especially after a stroke. However, they do not provide the mechanical stress needed to strengthen bones and prevent osteoporosis like weight-bearing exercises do.

 

References

• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.

EXPLANATION

 

✔Correct answer:

Positioning the patient on their back with a small pillow under their head. When providing oral hygiene to a patient who has suffered a stroke, it is crucial to avoid positioning them on their back with a small pillow under their head. This position increases the risk of aspiration, especially in patients who may have impaired swallowing reflexes or decreased level of consciousness. Aspiration can lead to pneumonia and other serious respiratory complications.

After a stroke, many patients experience dysphagia (difficulty swallowing) due to impaired muscle control and neurological damage. Lying flat on the back can cause oral secretions, food particles, or fluids to enter the airway instead of being swallowed properly, increasing the risk of aspiration.

Imagine trying to drink water while lying flat on your back. It's difficult to swallow properly, and there's a high chance of choking. Similarly, a stroke patient is at risk of aspiration when in this position during oral care.

Nurse Ramirez should take appropriate measures to ensure safe oral hygiene practices, which include:

• Position the patient in a side-lying or upright position to reduce the risk of aspiration.
• Ensure the patient’s head is turned to the side or slightly forward to allow secretions to drain out of the mouth instead of back toward the throat.
• Use a padded tongue blade carefully to avoid injuring the patient while opening their mouth.
• Have portable suctioning equipment readily available to remove secretions and prevent aspiration.
• Clean the patient’s mouth and teeth with a toothbrush to maintain oral hygiene and prevent infections.

 

✘Incorrect answer options:

Having portable suctioning equipment readily available at the bedside. This is a necessary precaution to promptly remove secretions and prevent aspiration, making it a critical component of safe oral hygiene for stroke patients.

Using a padded tongue blade to open the patient's mouth. A padded tongue blade can help gently open the patient's mouth without causing injury, facilitating thorough cleaning of the oral cavity.

Cleaning the patient’s mouth and teeth with a toothbrush. Regularly cleaning the mouth and teeth with a toothbrush is essential for maintaining oral hygiene, preventing infections, and promoting overall health.

 

References

• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.

EXPLANATION

 

✔Correct answer:

A TIA can serve as an indicator of a potential cerebrovascular accident (CVA). A transient ischemic attack (TIA) is often referred to as a "mini-stroke" because it involves temporary disruption of blood flow to the brain, resulting in stroke-like symptoms that resolve within 24 hours. The key point that Nurse Patel should emphasize is that a TIA is a warning sign indicating an increased risk of a future cerebrovascular accident (CVA or stroke). Patients who experience a TIA are at higher risk of having a stroke, and timely medical intervention and lifestyle changes are crucial to reduce this risk.

A TIA occurs when a blood clot temporarily blocks an artery in the brain, causing a brief period of reduced blood flow. This blockage can lead to symptoms such as sudden weakness, numbness, confusion, trouble speaking, or loss of balance, which resolve quickly as the blockage clears. However, the presence of a TIA suggests underlying vascular issues that could result in a full-blown stroke if not addressed.

Think of a TIA as a small, temporary blockage in a water pipe that clears on its own. However, it indicates that the pipe is at risk for a more significant blockage in the future, which could cause more severe damage. Similarly, a TIA indicates an increased risk for a full stroke.

Educating the patient about the importance of recognizing TIA symptoms and seeking immediate medical care is vital.

• Inform Mr. Lawson that a TIA is a serious warning sign of a potential stroke and requires medical attention.
• Encourage lifestyle modifications to reduce stroke risk, such as quitting smoking, eating a healthy diet, exercising regularly, and managing hypertension, diabetes, and cholesterol levels.
• Discuss the importance of adhering to prescribed medications that reduce stroke risk, such as antiplatelets or anticoagulants.
• Educate about the symptoms of a stroke using the FAST acronym (Face drooping, Arm weakness, Speech difficulty, Time to call emergency services).
• Ensure Mr. Lawson understands the need for regular follow-up appointments to monitor and manage his health conditions.

 

✘Incorrect answer options:

Symptoms of a TIA can persist for 24 to 48 hours. TIA symptoms typically resolve within 24 hours. If symptoms persist beyond 24 hours, it is more likely classified as a stroke rather than a TIA.

Most individuals retain some residual effects post-TIA. By definition, a TIA does not cause permanent damage or residual effects. Symptoms resolve completely within a short period.

The primary symptom of a TIA is difficulty in speaking. While difficulty speaking can be a symptom of a TIA, it is not the primary or only symptom. TIAs can present with a variety of symptoms, including weakness, numbness, vision changes, and loss of balance, depending on the area of the brain affected.

 

References

• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.

EXPLANATION

 

✔Correct answer:

Ensuring Mrs. Thompson's safety to prevent falls and further injury. Safety is the top priority for patients with hemiparesis resulting from a cerebrovascular accident (CVA or stroke). Hemiparesis, or weakness on one side of the body, significantly increases the risk of falls and injuries. Ensuring a safe environment and taking precautions to prevent falls is critical to protect the patient from additional harm and complications.

Hemiparesis occurs due to damage to the motor pathways in the brain responsible for voluntary muscle movement. This condition impairs the patient’s balance, coordination, and ability to move safely, making them vulnerable to falls and subsequent injuries, such as fractures or head trauma.

Think of a person trying to walk on an icy path. Their lack of stability and control increases the likelihood of slipping and falling. Similarly, a patient with hemiparesis has compromised stability and needs extra measures to prevent falls.

Ensuring the safety of a patient with hemiparesis involves creating a secure environment and employing strategies to reduce the risk of falls.

• Assess the patient's environment to identify and remove potential hazards (e.g., loose rugs, clutter).
• Use assistive devices like walkers or canes as needed to aid mobility.
• Ensure that the patient’s bed is in a low position with side rails as appropriate.
• Provide non-slip footwear and educate the patient on safe movement techniques.
• Implement a fall prevention protocol, including regular checks and prompt response to call lights.
• Encourage the presence of a caregiver or support person during ambulation and ADLs.

 

✘Incorrect answer options:

Encouraging Mrs. Thompson to perform daily exercises to improve muscle strength. While exercise is important for recovery and muscle strengthening, it is not the immediate top priority compared to ensuring patient safety. Exercises can be incorporated into the care plan once safety measures are firmly in place.

Assisting Mrs. Thompson with activities of daily living (ADLs) to promote independence. Assisting with ADLs is important for promoting independence and improving quality of life, but safety measures must be prioritized first to prevent falls and injuries during these activities.

Monitoring Mrs. Thompson's neurological status regularly for changes. Regular neurological assessments are essential for tracking the patient's progress and detecting any changes in condition, but they do not directly address the immediate risk of falls and injuries due to hemiparesis.

 

References

• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.

EXPLANATION

 

✔Correct answer:

Addressing the cause of tarry stools and potential gastrointestinal bleeding. Tarry stools (melena) indicate the presence of digested blood, usually from upper gastrointestinal bleeding. This, along with Mr. Brown’s low blood pressure (90/50 mm Hg) and low hemoglobin level (10 g/dl), suggests significant blood loss, which could be life-threatening if not addressed promptly. Identifying and treating the source of the gastrointestinal bleeding is crucial to prevent further deterioration and to stabilize his condition.

Gastrointestinal bleeding can lead to hypovolemia (reduced blood volume), which in turn can cause hypotension and decreased hemoglobin levels due to the loss of red blood cells. The body's compensatory mechanisms may be overwhelmed, especially in an elderly patient or one with a cerebrovascular accident, leading to shock if the bleeding is not controlled.

Imagine a pipe with a significant leak that is causing water pressure to drop rapidly. The priority would be to locate and fix the leak to prevent flooding and further damage, just as stopping gastrointestinal bleeding is crucial to stabilize the patient’s condition.

Nurse Julie should focus on interventions that address the gastrointestinal bleeding and stabilize Mr. Brown's hemodynamic status.

• Perform a stool test for occult blood to confirm gastrointestinal bleeding.
• Notify the physician immediately about the suspected GI bleeding, hypotension, and anemia.
• Prepare for potential interventions such as endoscopy, blood transfusions, or medications to control bleeding.
• Monitor vital signs frequently, including blood pressure, heart rate, and hemoglobin levels.
• Ensure the patient remains in a safe and comfortable position and administer IV fluids or medications as ordered to stabilize blood pressure.

 

✘Incorrect answer options:

Administering medication to increase blood pressure. While raising blood pressure is important, it addresses the symptom rather than the underlying cause. Treating the gastrointestinal bleeding will help resolve the hypotension more effectively.

Assisting with activities of daily living due to left-sided weakness. Assisting with ADLs is important but not the immediate priority. Stabilizing his hemodynamic status and addressing the cause of tarry stools is more urgent.

Managing bowel incontinence to prevent skin breakdown. Preventing skin breakdown is important, especially with incontinence, but it is secondary to addressing the potentially life-threatening GI bleeding.

 

References

• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.

EXPLANATION

 

✔Correct answer:

An oral anticoagulant therapy. Patients with atrial fibrillation (AFib) are at increased risk of thromboembolic events, such as transient ischemic attacks (TIAs) and strokes, due to the formation of blood clots in the atria that can travel to the brain. An oral anticoagulant is typically prescribed to prevent further clot formation and reduce the risk of future TIAs and strokes. Common oral anticoagulants include warfarin, apixaban, dabigatran, and rivaroxaban.

Atrial fibrillation causes irregular and often rapid heartbeats, leading to ineffective atrial contractions. This can result in blood pooling in the atria, particularly the left atrium, which increases the risk of clot formation. These clots can embolize and travel to the brain, causing a TIA or stroke. Anticoagulants work by inhibiting the blood’s ability to clot, thereby reducing the risk of emboli formation.

Imagine a busy highway where cars (blood) move smoothly. Atrial fibrillation is like a malfunctioning traffic light causing cars to stop and go irregularly, leading to traffic jams (clots). An oral anticoagulant is like a traffic officer who keeps the cars moving steadily, preventing jams and ensuring smooth flow, reducing the risk of accidents (strokes).

Nurse Davis should educate Mr. Robinson about the importance of adhering to the prescribed anticoagulant therapy and provide information on managing the medication safely.

• Educate the patient on the purpose of anticoagulant therapy and its role in preventing strokes and TIAs.
• Instruct the patient on the proper dosage and timing of the medication to ensure therapeutic levels are maintained.
• Inform the patient about potential side effects, such as bleeding, and the importance of monitoring for signs of excessive bleeding (e.g., unusual bruising, blood in urine or stool).
• Discuss the need for regular blood tests if warfarin is prescribed to monitor INR (International Normalized Ratio) levels and adjust the dose as needed.
• Encourage the patient to avoid activities or substances that increase the risk of bleeding, such as certain medications (e.g., NSAIDs) and alcohol.

 

✘Incorrect answer options:

A beta-blocker prescription. Beta-blockers are commonly used to manage heart rate and blood pressure in patients with atrial fibrillation but do not address the risk of clot formation and embolic events. They are not the primary choice for preventing TIAs or strokes.

A medication to lower uric acid levels. Medications to lower uric acid levels are used to treat gout, not to prevent thromboembolic events associated with atrial fibrillation.

A thrombolytic treatment. Thrombolytics are used acutely to dissolve existing clots during a stroke or myocardial infarction but are not used for long-term prevention of TIAs or strokes. Long-term prevention focuses on preventing clot formation with anticoagulants.

 

References

• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.

EXPLANATION

 

✔Correct answer:

Atrial septal defect. An atrial septal defect (ASD) is a congenital heart defect that involves an abnormal opening in the atrial septum, which allows blood to flow between the left and right atria. This condition can lead to a paradoxical embolism, where a blood clot from the venous circulation passes through the defect and into the arterial system, potentially traveling to the brain and causing a cerebrovascular accident (CVA or stroke).

In individuals with an atrial septal defect, increased pressure in the right atrium can cause a right-to-left shunt, especially during activities that increase intrathoracic pressure (such as straining or coughing). This shunt allows venous blood clots to bypass the lungs (where they would typically be filtered out) and enter the arterial circulation, increasing the risk of embolic stroke.

Imagine a security checkpoint at an airport where bags are screened for dangerous items. An ASD is like a secret passage that bypasses the checkpoint, allowing a potentially dangerous item (a blood clot) to reach its destination unchecked, potentially causing harm (a stroke).

Nurses should monitor patients with congenital heart disease for signs of embolic events and collaborate with the healthcare team to manage and mitigate the risks.

• Assess for symptoms of stroke, such as sudden weakness, confusion, difficulty speaking, and loss of balance.
• Encourage regular follow-up with a cardiologist to monitor the heart condition and manage complications.
• Educate the patient about the importance of anticoagulation therapy if prescribed to reduce the risk of blood clots.
• Promote lifestyle modifications to reduce the overall risk of cardiovascular events, such as a healthy diet, regular exercise, and smoking cessation.

 

✘Incorrect answer options:

Mitral valve prolapse. Mitral valve prolapse is a condition where the mitral valve bulges into the left atrium during systole. While it can be associated with arrhythmias and sometimes endocarditis, it is less commonly linked directly to an increased risk of embolic stroke compared to ASD.

Ventricular tachycardia. Ventricular tachycardia is a type of fast heart rhythm originating from the ventricles. It is a serious condition that can lead to cardiac arrest, but it is not typically associated with embolic stroke. The focus here is on the potential for life-threatening arrhythmias rather than embolic events.

Pericarditis. Pericarditis is inflammation of the pericardium, the sac surrounding the heart. It can cause chest pain and other symptoms but is not directly linked to an increased risk of stroke through embolic mechanisms like an atrial septal defect.

 

References

• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.

EXPLANATION

 

✔Correct answer:

Frequently reposition him. The most effective intervention to prevent the development of pressure ulcers in a patient who is too weak to move independently is frequent repositioning. Pressure ulcers, also known as bedsores, develop when prolonged pressure on the skin restricts blood flow, leading to tissue damage. Repositioning the patient regularly helps to relieve pressure on vulnerable areas and promote blood circulation, thereby preventing skin breakdown.

Pressure ulcers are most likely to develop on bony prominences such as the sacrum, heels, and hips, where there is less cushioning from muscle and fat. By frequently changing the patient's position, the nurse can ensure that no single area of skin is subjected to prolonged pressure. This intervention helps to distribute weight more evenly and allows for better blood flow to all areas of the skin.

Think of sitting on a hard chair for an extended period without moving. Eventually, certain areas become uncomfortable due to the constant pressure. If you shift your position regularly, you can avoid discomfort and prevent sore spots. Similarly, frequent repositioning in bedridden patients helps prevent pressure ulcers.

Implementing a regular repositioning schedule is crucial in the care plan for Mr. Johnson.

• Reposition Mr. Johnson every two hours: Use pillows, wedges, and other supportive devices to maintain new positions and relieve pressure on vulnerable areas.
• Inspect skin regularly: Check for early signs of pressure ulcers, such as redness, warmth, or skin breakdown, especially over bony prominences.
• Use pressure-relieving devices: Employ special mattresses, cushions, and overlays that help reduce pressure on the skin.
• Maintain skin hygiene: Keep the skin clean and dry to prevent maceration and infection, which can increase the risk of pressure ulcers.
• Ensure adequate nutrition and hydration: Proper nutrition and hydration support skin integrity and healing.

 

✘Incorrect answer options:

Conduct passive range-of-motion (ROM) exercises. While passive ROM exercises are beneficial for maintaining joint flexibility and preventing contractures, they do not directly address the prevention of pressure ulcers. ROM exercises are important but should not be the primary intervention for pressure ulcer prevention.

Limit his fluid intake. Limiting fluid intake is not appropriate for preventing pressure ulcers and could potentially harm the patient. Adequate hydration is essential for skin health and overall bodily functions.

Advise the use of a footboard. A footboard can help prevent foot drop and support proper alignment, but it does not directly prevent pressure ulcers. Repositioning is more critical for pressure ulcer prevention.

 

References

• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.
• National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. (2014). Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline.

EXPLANATION

 

✔Correct answer:

The UAP supports the patient by placing her hand under the patient’s right axilla to help him move up in bed.  Supporting a patient by placing a hand under their axilla (armpit) to help them move up in bed is an incorrect technique that can cause injury. This action can lead to shoulder dislocation or damage, especially in patients with right-sided paralysis who may have weakened or spastic muscles. Instead, proper body mechanics and safer techniques, such as using a draw sheet or assisting with a lift, should be used to help the patient move.

Right-sided paralysis results from a stroke affecting the left side of the brain, impairing motor function on the opposite side of the body. The muscles and joints on the paralyzed side are more susceptible to injury due to weakness, spasticity, or lack of support.

Imagine lifting a fragile object with a broken handle; improper handling can cause further damage. Similarly, using incorrect techniques to move a patient with paralysis can lead to injuries.

Nurse Taylor should intervene to correct the UAP’s technique and provide guidance on safe methods to assist the patient.

• Instruct the UAP to use a draw sheet or slide sheet to move the patient up in bed, reducing the risk of shoulder injury.
• Demonstrate proper body mechanics and lifting techniques to ensure patient safety and prevent caregiver injury.
• Reinforce the importance of supporting the patient's entire body, especially the affected side, during movements and transfers.
• Monitor the patient for any signs of discomfort or injury, particularly in the shoulder area.
• Provide ongoing education and training to UAPs on the safe handling and transfer techniques for patients with paralysis.

 

✘Incorrect answer options:

The UAP places a gait belt around the patient’s waist before assisting with ambulation. Using a gait belt is a standard practice to provide support and stability during ambulation, ensuring patient safety and preventing falls.

The UAP positions the patient on their back with their head turned to the side. Positioning the patient on their back with their head turned to the side can help maintain an open airway and prevent aspiration, especially in patients with difficulty swallowing or those at risk of aspiration.

The UAP praises the patient for attempting to perform activities of daily living (ADLs) independently. Praising the patient for attempting to perform ADLs independently is a positive reinforcement strategy that encourages independence and boosts the patient’s confidence in their abilities.

 

References

• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.

EXPLANATION

 

✔Correct answer:

A cerebrovascular accident (CVA). Seizures in a child who has recently undergone corrective surgery for Tetralogy of Fallot are most likely due to a cerebrovascular accident (CVA), or stroke. Children with congenital heart defects, such as Tetralogy of Fallot, are at higher risk for cerebrovascular complications due to factors like altered hemodynamics, potential intraoperative complications, and possible emboli formation during or after surgery. A stroke can result in seizures due to the acute disruption of blood flow to the brain, leading to neuronal injury and excitability.

Tetralogy of Fallot is a congenital heart defect involving four anatomical abnormalities, which can significantly affect blood flow. Corrective surgery aims to repair these defects, but the procedure can sometimes lead to complications, including the formation of blood clots that can travel to the brain, causing a stroke. In children, a stroke can present with seizures, sudden weakness, and other neurological symptoms.

Imagine a water pipe system where a major blockage suddenly disrupts the flow of water, causing bursts and leaks. Similarly, a stroke disrupts the blood flow in the brain, leading to seizures as the brain tissue is damaged.

Nurse Karen should prioritize immediate assessment and intervention for suspected stroke, including:

• Monitoring the child's neurological status and vital signs closely.
• Notifying the physician immediately about the new onset of seizures.
• Preparing the child for diagnostic imaging, such as a CT scan or MRI, to confirm the presence of a stroke.
• Administering anticonvulsant medications as prescribed to control seizures.
• Providing supportive care and monitoring for additional complications.

 

✘Incorrect answer options:

Postoperative meningitis. Postoperative meningitis could cause seizures, but it is less likely in this context. Meningitis typically presents with symptoms such as fever, neck stiffness, and altered mental status, rather than isolated new-onset seizures.

A reaction to medication. While medication reactions can cause seizures, the sudden onset of seizures in the context of recent heart surgery points more towards a cerebrovascular event rather than a medication reaction. Additionally, there would typically be other signs of medication toxicity or side effects.

Metabolic alkalosis. Metabolic alkalosis is a disturbance in the body's acid-base balance, usually presenting with symptoms such as muscle twitching or cramps, but it is an unlikely cause of seizures following cardiac surgery. The clinical context and risk factors point more towards a stroke.

 

References

• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.