Question: A 65-year-old patient is admitted to the emergency department with sudden-onset slurred speech, facial droop, and weakness on one side of the body. The initial assessment reveals a blood pressure of 180/100 mmHg, and the patient is unable to lift the left arm. What is the priority nursing intervention?
a) Administer antihypertensive medication
b) Perform a complete neurological assessment
c) Administer a thrombolytic agent
d) Prepare for immediate transfer to the radiology department for a CT scan
e) Elevate the head of the bed to 45 degrees
Rationale: Rapid assessment and diagnosis are crucial in suspected stroke cases. A CT scan is essential to differentiate between ischemic and hemorrhagic strokes, guiding appropriate treatment. Administering antihypertensive medication without confirming the type of stroke can worsen outcomes. While a complete neurological assessment is important, obtaining a CT scan takes precedence for timely decision-making. Thrombolytic agents are indicated for ischemic strokes, but their administration requires confirmation through imaging. Elevating the head of the bed is a measure for managing increased intracranial pressure, not the immediate priority. Correct Answer: d) Prepare for immediate transfer to the radiology department for a CT scan
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A patient diagnosed with an ischemic stroke is receiving alteplase (tPA). The nurse should monitor the patient for which potential complication?
a) Hypotension
b) Hyperglycemia
c) Hemorrhagic transformation
d) Bradycardia
e) Hypokalemia
Rationale: Alteplase is a thrombolytic agent used to dissolve blood clots in ischemic strokes. However, a potential complication is hemorrhagic transformation, where bleeding occurs within the infarcted area. Monitoring for signs of increased intracranial pressure and neurologic deterioration is crucial. While hypotension can occur, it is not a specific complication of alteplase. Hyperglycemia may exacerbate brain injury but is not a direct effect of tPA. Bradycardia and hypokalemia are not commonly associated with thrombolytic therapy. Correct Answer: c) Hemorrhagic transformation
NCLEX Questions Critical Thinking: Stroke Symptoms
A patient with a history of atrial fibrillation is prescribed warfarin (Coumadin) for stroke prevention. The nurse should educate the patient about which dietary consideration?
a) Limiting vitamin C intake
b) Consistent intake of foods rich in vitamin K
c) Avoiding high-fiber foods
d) Increasing calcium-rich foods
e) Consuming a low-protein diet
Rationale: Warfarin is a vitamin K antagonist, and maintaining a consistent intake of vitamin K-containing foods helps stabilize the anticoagulant effect. Vitamin C, fiber, calcium, and protein intake do not significantly impact warfarin therapy. Inconsistent vitamin K intake can affect the medication’s efficacy, leading to variations in the International Normalized Ratio (INR). Therefore, educating the patient about the importance of a stable vitamin K intake is essential for optimal anticoagulation management. Correct Answer: b) Consistent intake of foods rich in vitamin K
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NCLEX Review: Stroke Treatments
A 72-year-old patient is admitted to the emergency department with sudden confusion, severe headache, and difficulty walking. The family reports that the patient has a history of atrial fibrillation. The nurse observes unequal pupil size and decreased consciousness. What should the nurse prioritize in the care of this patient?
a) Administering an antiplatelet medication
b) Initiating thrombolytic therapy
c) Monitoring blood glucose levels
d) Assessing for signs of increased intracranial pressure
e) Encouraging active range of motion exercises
Rationale: The symptoms and history suggest a potential hemorrhagic stroke. Assessing for signs of increased intracranial pressure, such as changes in consciousness and unequal pupil size, is crucial for early detection of worsening condition. Administering an antiplatelet medication is more applicable to ischemic strokes, while thrombolytic therapy is contraindicated in hemorrhagic strokes. Monitoring blood glucose levels is important but not the priority in this situation. Encouraging active range of motion exercises is not indicated in the acute phase of a stroke. Correct Answer: d) Assessing for signs of increased intracranial pressure
NCLEX Focus Exploring Stroke: Causes and Diagnosis
A patient with a recent ischemic stroke is prescribed clopidogrel (Plavix) as part of the treatment plan. What education should the nurse provide to the patient?
a) Take the medication with a glass of milk
b) Report any signs of excessive bleeding
c) Discontinue the medication if experiencing nausea
d) Consume a diet high in vitamin K
e) Crush the tablet before administration if difficulty swallowing
Rationale: Clopidogrel is an antiplatelet medication that reduces the risk of blood clot formation. Patients should be educated to report any signs of excessive bleeding, such as easy bruising or blood in stool or urine, as it may indicate a complication of the medication. Taking the medication with milk is not specified in the administration instructions. Discontinuing the medication without consulting the healthcare provider is not advised. A diet high in vitamin K is more relevant for patients on warfarin, not clopidogrel. Crushing the tablet is generally not recommended unless specifically instructed by the healthcare provider. Correct Answer: b) Report any signs of excessive bleeding
Understanding Stroke: NCLEX Priority Questions
A patient with a history of hypertension is admitted with left-sided weakness and slurred speech. The initial CT scan reveals an ischemic stroke. What medication should the nurse anticipate administering to this patient?
a) Alteplase (tPA)
b) Clopidogrel (Plavix)
c) Warfarin (Coumadin)
d) Nitroglycerin
e) Labetalol (Trandate)
Rationale: Alteplase is a thrombolytic agent indicated for the treatment of ischemic strokes. Administering tPA within the first few hours of symptom onset can help dissolve the clot and improve outcomes. Clopidogrel is an antiplatelet medication, warfarin is an anticoagulant, nitroglycerin is used for angina, and labetalol is a beta-blocker; none of these are the primary medications for treating an acute ischemic stroke. Early intervention with tPA is essential for maximizing the chances of recovery in ischemic strokes. Correct Answer: a) Alteplase (tPA)
Understanding Stroke: NCLEX Delegation Questions
A 68-year-old patient with a history of hypertension and diabetes is admitted with sudden-onset right-sided weakness and difficulty speaking. The initial assessment reveals a blood pressure of 160/90 mmHg. What is the priority nursing intervention?
a) Administering an anticoagulant
b) Initiating thrombolytic therapy
c) Controlling blood pressure
d) Ordering a brain MRI
e) Assessing blood glucose levels
Rationale: In the acute phase of ischemic stroke, controlling blood pressure is a priority to prevent further damage and improve outcomes. Thrombolytic therapy may be considered but is contraindicated if the blood pressure is not within an acceptable range. Administering an anticoagulant is not the immediate priority in the acute phase. Ordering a brain MRI may be done later for detailed imaging but is not the initial intervention. Assessing blood glucose levels is important, but controlling blood pressure takes precedence to minimize the impact of the stroke. Correct Answer: c) Controlling blood pressure
Understanding Stroke: Causes and Symptoms
A patient with a history of atrial fibrillation is prescribed rivaroxaban (Xarelto) for stroke prevention. What information should the nurse include in the education plan for this patient?
a) Avoiding foods high in vitamin K
b) Reporting any signs of excessive bleeding
c) Taking the medication with grapefruit juice
d) Discontinuing the medication if experiencing palpitations
e) Consuming a low-fiber diet
Rationale: Rivaroxaban is an anticoagulant, and patients should be educated to report signs of excessive bleeding, such as easy bruising or blood in stool or urine. Avoiding foods high in vitamin K is more relevant for patients on warfarin. Taking the medication with grapefruit juice is not specified in the administration instructions. Discontinuing the medication without consulting the healthcare provider is not advised. Consuming a low-fiber diet is not directly related to rivaroxaban therapy. Correct Answer: b) Reporting any signs of excessive bleeding
NCLEX Practice Questions: Understanding Stroke Causes and Symptoms
A patient who recently experienced an ischemic stroke is prescribed aspirin for secondary prevention. What is the primary purpose of aspirin in this context?
a) Dissolving existing blood clots
b) Preventing platelet aggregation
c) Reducing blood pressure
d) Promoting cerebral vasodilation
e) Inhibiting inflammation
Rationale: Aspirin is an antiplatelet medication that works by preventing platelet aggregation, reducing the risk of further clot formation in patients with a history of ischemic stroke. It does not dissolve existing blood clots, reduce blood pressure, promote cerebral vasodilation, or primarily inhibit inflammation. The antiplatelet effect of aspirin is crucial for preventing recurrent vascular events in patients with a history of ischemic stroke. Correct Answer: b) Preventing platelet aggregation
NCLEX Questions: Focus on Medications for Stroke
A patient admitted with a hemorrhagic stroke is at risk for increased intracranial pressure. What nursing intervention should be prioritized to manage this complication?
a) Administering an antihypertensive medication
b) Elevating the head of the bed to 90 degrees
c) Encouraging coughing and deep breathing exercises
d) Administering acetaminophen for pain relief
e) Maintaining a quiet, dimly lit environment
Rationale: In the case of a hemorrhagic stroke, managing increased intracranial pressure is crucial. Maintaining a quiet, dimly lit environment helps reduce stimuli that may exacerbate intracranial pressure. Administering an antihypertensive medication may be considered, but it is not the initial priority. Elevating the head of the bed to 90 degrees is contraindicated in hemorrhagic strokes as it may increase pressure. Coughing and deep breathing exercises may be beneficial for respiratory function but are not the primary intervention. Acetaminophen may be used for pain relief, but the priority is creating an optimal environment to minimize intracranial pressure. Correct Answer: e) Maintaining a quiet, dimly lit environment