Cerebral-vascular Accidents. By: Emma Fleck. O bjectives. Pathophysiology/types/signs Relevance to population: age, gender , congenital Current treatment and modalities Diagnostic tests/labs Medications Prognosis/outcome N ursing diagnosis NCLEX questions. P athophysiology.
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By: Emma Fleck
(Ackley & Ladwig, 2011)
A 78 year old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority?
During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to control the client’s:
c. Blood pressure
A patient with a stroke experiences right-sided arm and leg paralysis and facial drooping on the right side. When obtaining admission assessment data about the patient's clinical manifestations, it is most important the nurse assess the patient's
The nurse identifies the nursing diagnosis of impaired verbal communication for a patient with expressive aphasia. An appropriate nursing intervention to help the patient communicate is to
a. ask simple questions that the patient can answer with "yes" or "no."
b. develop a list of words that the patient can read and practice reciting.
c. have the patient practice facial and tongue exercises to improve motor control necessary for speech.
d. prevent embarrassing the patient by changing the subject if the patient does not respond in a timely manner
A patient has a stroke affecting the right hemisphere of the brain. Based on knowledge of the effects of right brain damage, the nurse establishes a nursing diagnosis of
a. impaired physical mobility related to right hemiplegia.
b. impaired verbal communication related to speech-language deficits.
c. risk for injury related to denial of deficits and impulsiveness.
d. ineffective coping related to depression and distress about disability.
A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering the medications, the patient says, "I don't need the aspirin today. I don't have any aches or pains." Which action should the nurse take?