Stroke Questions and Rationales

Stroke Question Which action can the RN delegate to the unlicensed assistive personnel to reduce fatigue for a patient recovering from a stroke at mealtimes? Which nursing intervention would be included in the plan of care for a patient wo is admitted with stroke and is complaining about having liquid stools? A RN is admitting a pt with a thrombotic stroke. The pt is NPO BUT requesting a drink of water. Which response by the RN is appropriate? Which food would be included in the Answer A)Feed the pt the meal B)Provide water during the meal C) Cut up the meat for the patient D) Place the head of the bed at 30 degrees Rationale The RN should instruct the UAP to cut up the meat at mealtimes and to assist with eating as needed. The ability to drink water during the meal may be limited if the patient has problems swallowing, but this will not address fatigue. Placing the head of the bed at 30 degrees is not high enough for eating and will not reduce fatigue during the meal. Feeding the patient reduces independence and should be avoided as the first action. A.Administer enema Stool impaction is the development of a solid immobile B. Administer psyllium mass of fecal matter in the rectum, which may result in C. Check for stool impaction liquid stool. Therefore the nurse should assess for this D. Discourage physical activity first. An enema hekps to facilitate howel movements but should be avoided because it increases the intracranial pressure. Psyllium is a form of fiber used to increase the solid amss in the intestine so that the feces can pass easily. Physical activity stimulates bowel function, so the rn should encourage the patient to perform phsycial activity. A. You can have a couple of ice chips Stroke patients are at high risk for aspiration pneumonia. to wet your mouth The centers for Medicare and Medicaid Services- CMS B. A barium swallow test is required recommends that patients be kept strict NPO until cleared for stroke patients before giving PO by a swallow screen or swallow evaluation. Strinct NPO fluids includes ice chips, all fluids, food, and oral medications. C. We need to keep you NPO in case A barium swallow tessst is not required for all strok a procedure needs to be performed patients but is performed on individuals with inconvlusive today swallow screening or evaluations. “we need to keep you D. It is not safe to allow you to have NPO in case a procedure needs to be formed today” is anything by mouth until a swallow incorrect because the primary reason a patient is kept Npo assessment can be performed. is the high risk of aspiration pneumoni. a. Milkshakes Pts who had a stroke and have dysphagia have difficulty diet for a patient who had a stroke and has dysphagia? Which information would be given to the patient with a history of transient ischemic attacks and has been prescribed aspirin? SELECT ALL THAT APPLY Which behavior would be exhibited by a patient who has suffered a rightbrain stroke Which action would be beneficial to a patient with a right brain stroke? Which food items would be included in the diet plan for a patient being discharged from the hospital after recovering from a stroke? SELECT ALL THAT APPLY A RN is measuring the BP of a hypertensive obese pt who has been b. Chicken soup c. Mashed potatoes d. Pureed cooked rice a. It is only a pain med b. It is used to break up clots c. It is okay to lower the dose if you fee well d. It is pain medication and an antiplatelet agent e. It may cause bleeding, which should be reported immediately. a. Very cautious b. Difficulty with words c. Impulsive and impatient d. Accomplishes tasks quickly a. Wear shoes when out of bed b. Arrange food on the left side c. Remove clutter and obstacles d. Give directions nonverbally A. Pizza B. French Fries C. Cheeseburger D. Vegetable Soup E. Grilled chicken A. Refer the pt to a speech therapist B. Treat this as an emergency and chewing and swallowing. Thus the RN would include mashed potatoes becaue the food is easy to swallow and provides enough texture. Milkshakes and ALL MILK products should be avoided bc they increase the viscosity of mucus, which leads to an increase in salivation. Chicken soup is a thin liquid that may be difficult to swallow and could trigger coughing or choiking. Pureed cooked rice is bland to the taste and may stick to the palate, which poses a risk for aspiration. Aspirin is not only a pain med BUT also an antiplatelet agent. Aspirin may cause bleeding if taken for a long duration, which should be reported to the HCP. It helps to prevent clots by inhibiting platelets from sticking together. The pt should not increase or decrease the dose of aspririn without consulting their hcp. Patients who suffered from strokes on the right side of brain will behave impusively and act impatiently. Left brain stroke surviros are aware of the deficiency and failure in mental functioning and become very cautious. Right brain stroke survivors are at a higher risk for injur due to mobility issues. Therefore all clutter and obstacles should be removed, and proper lighting should be provided. Patients recovering from a stroke should follow dietary restrictions. The diet should be low in fats, hence grilled chicken. Diets high in fruits and vegetables reduce the risk for stroke. Obesity, high BP, and diabetes are all RISK FACTORS for STROKE. Sudden fumbling of the pt or sudden admitted to the hospital for increased BG levels. While the pt is speaking, the RN notes that the pt has suddenly started mubling and is unale to articulate words. Which action would the nurse take? When feeding a patient with a stroke on the left side, which postion would the RN place the patient? call the HCP C. Ensure the pt he/she should not worry about the illness D. Ask the pt to protrude the tongue to test the hypoglossal nerve a. b. c. d. a. During the acute stage of a stroke, which intervention would be included in the plan of care for a patient experiencing aphasia? Which expected outcome would be included in the plan of care for a patient who had a stroke and is experiencing residual expressive aphasia? a. b. c. d. Which rationale is accurate for why the use of video games would be Right lateral position Low fowlers position High fowlers position Trendelenburgs position Ask simple yes and no questions b. Limit verbal communication to reduce frustration c. If pt is unable to answer a question, divert eye contact to reduce embarrassment d. If pt does not answer immediately, ask pt if he/she understands or needs the info repeated The patient will verbalize plans for rehabilitation. The pt will be satisfied with the care environment The pt will demonstrate alternative communication techniques The patient will demonstrate understanding that the aphasia is permanent. a. The pt’s anxiety can be improved slurred speech is considered a transient ischemic attack (TIA) and a warning sign of stroke. It should be considered an emergency, and the hcp should be incomred. High fowlers position is sitting upright. This helps in feeding, as well as swallowing, for the patient. Asking questions that can be answered simply supports communication in the acute phase of a stroke. Verbal communication should not be limited but should be frequent and meaningful. Diverting eyecontact is incorrect bc it will increase embarrassment instead of reducing it. It is important to give the pt time to answer a questions. Asking a second question before the pt has time to answer the first will only increase frustrations and decrease communication. Pts with expressive aphasia require teaching and encuragment to use alternative techniques of communication to make their needs known and interact with others. Pts with expressive aphasia may not be able to communicate verbally, however, they may still communicate using other techniques such as vocal sounds or eye movements. A satisfactory enviornonment is not a realated outcome for expressive aphasia. In some cases, expressive aphasia may not be permanent. Video games can improve motor skills becaue the brain, nervous system and muscles work together while playing. included in the plan of care for a patient who sustained a stroke? A patient has left sided hemiplegia following an ischemic stroke that was experienced 4 days earlier. How would the nurse best promote the health of the patients integumentary system? Which intervention would the RN delegate to the experienced UAP when working with ap t who had a stroke? Which aspects of the medical history of a female patient are risk factors for Stroke? SELECT ALL THAT APPLY b. The pt’s aphasia can be improved c. The pt’s hemiplegia can be improved d. The pts motor skills can be improved A. Position the p toon the weak side most of the time. B. Alternate the pt positioning between supine and side lying C. Avoid use of pillows to promote independence in positioning D. Establish a schedule for the massage of areas where skin breakdown emerges a. Suction oral pharynx PRN b. Assess orientation every four hours c. Perform passive range-of motion exercises to flaccid extremities d. Ensure gag reflex is intact before offering fluids or food a. Chronic low back pain b. Current use of high dose oral contraceptives c. History of long standing hair loss d. History of migraine A position change schedule should be established for patients who had a stroke. An example is side-back-side, with maximum duration of two hours for any position. The pt should be positioned on the weak or paralyzed side for only 30 minutes. Pillows may be used to facilitate positioning. Areas of skin breakdown should never be massaged. After appropriate training and evaluation, the UAP can perform passive range of motion exercises to patients who have had a stroke. Suctioning the oral pharynx, assessing the gag reflex, and level of orientation requires more advanced skills and evaluation thatn is in the socrpe of practice of the UAP. Which nursing interventions would assist the patient who had a right brain stroke in cooping with perceptual deficits? SELECT ALL THAT APPLY headaches with aura e. Past employment involving exposure to chemical dyes A. Provide good lighting B. Break tasks into simple steps C. Provide nonslip socks at all times D. Allow the pt to move around in a wheelchair E. Give nonverbal cues and instructions for activities Right sided cerebrovascular accident (CVA) usually have difficulty judging position, distance, and rate of movement. Because of these spatial-perceptual deficits, the patient should wear nonslip socks at all times help move around safely. Any task given to the pt should be broken into small steps for ease of understanding. Good lighting should be provided for safe mobility.