Testing your Stroke Knowledge

1. Testing your Stroke Knowledge AANN Northern Illinois Chapter Symposium March 14, 2015 Presented By: Dee Behrens, RN, BSN, CNRN, SCRN Betty Berls, RN,BSN, CNRN

2. Objectives • Identify the anatomical location in the brain that correlates with specific stroke symptoms • Review neurological assessment in the stroke patient • Discuss nursing interventions in the care of ischemic and hemorrhagic patients • Recognize stroke risk factors

3. Course Content • Questions and answer format • Case Studies

4. A patient with Wernicke’s aphasia would have which one of the following findings on examination? • Slow, non-fluent speech • Inability to repeat words or sentences • Telegraphic speech • Inability to follow a command

5. Correct Answer is D Patients with Wernicke’s or receptive aphasia cannot understand what is being said to them. The speech may be fluent but has no meaning.

6. Dysfunction with cranial nerve IX and X increases risk for: • Aspiration • Hemi-inattention • Respiratory arrest • Infection

7. Answer is A

8. A patient is being discharged from the stroke unit who underwent an aneurysm clipping. The patient asks the nurse if the clip will be removed in the future. The correct response by the nurse is • In 3 months • When all symptoms resolve • Never • In 10 years

9. Correct Answer C Aneurysm clips can vary in size, shape and design but they are all placed with the intention of being permanent. Coils and stents are also intended to remain in place permanently but occasionally migrate or become loosened, requiring removal and/or replacement.

10. The MOST sensitive and specific imaging technique to demonstrate acute infarction is A. Non-contrast CT B. CT Perfusion Study C. CTA D. MR diffusion-weighted imaging

11. Correct Answer: D MR diffusion weighted imaging is the most sensitive to identifying the early stage of an acute ischemic stroke. It detects small restrictions in the movement of water molecules within the injured areas.

12. The NIHSS provides information on: • Medical History • Glascow Coma scale scores • Neurological deficits • NIHSS provides little information

13. Correct Answer: C NIHSS (National Institutes of Health Stroke Scale) is a tool utilized to score the severity of stroke symptoms. • Composed of 11 items • Each one scores a specific ability between 0-4 • Score of 0 in each category typically indicates normal function • Total score is a sum of all 11 items • Minimum score is a 0 while maximum is 42

14. An acute ischemic patient is being discharged with a new diagnosis of A-fib and will be going home on Warfarin. Discharge instructions include drug-food interactions. Which food item is the patient instructed to avoid: • Green Beans • Acorn Squash • Broccoli • Tomatoes

15. Correct Answer: C Patients taking warfarin should be taught to avoid foods high in Vitamin K. Most leafy green vegetables-collard greens, broccoli, avocados, brussel sprouts, cabbage, green onions. Also beef and pork liver, canola oil, margarine, mayonnaise, soybean oil

16. A 64yo African American male presents to the emergency room with c/o sudden onset of left leg weakness and numbness. Identify which blocked artery could cause these symptoms: • Posterior cerebellar artery • Left anterior cerebral artery • Basilar • Right anterior cerebral artery

17. Correct Answer: D Occlusion of the right anterior cerebral artery produces contralateral sensorimotor deficits mainly involving the lower extremity sparing the face and hands

18. A stroke in which area of the brain would be most devastating to a classical pianist? • Left cerebral hemisphere • Cerebellum • Right cerebral hemisphere • Brain stem

19. Correct Answer: C Functions of the right cerebellar hemisphere: • Controls left side of the body • Art Awareness • Creativity • Imagination • Intuition • Music Awareness • 3-D forms

20. An example of apraxia would be demonstrated by your patient presenting with which symptom? • Inability to name colors • Difficulty pronouncing multi-syllable words • Inability to show he can cut with imaginary scissors • Difficulty understanding the emotional and affective component of what is being said

21. Correct Answer: C Apraxia is the inability to perform a purposeful motor act on command. It can be seen with lesions of the dominant parietal lobe.

22. Right homonymous hemianopsia is described as: • Inability to see the left visual field in both eyes • Loss of vision in the right eye • Inability to see the right visual field in both eyes • Loss of vision in the left eye

23. Correct Answer: C Homonymous Hemianopsia is visual deficit affecting the same side (right or left) of each visual field. The patient must turn their head from side to side to compensate for the deficit.

24. A patient in his third day of admission since suffering a left MCA infarct becomes more aphasic with increased weakness of the right arm and leg. Repeat Stat head CT demonstrates increased vasogenic edema. Mannitol 25mg IV is ordered every 3 hours. What are the nurrsing considerations for this patient? • Need for hypertensive management, sedation and analgesia • Serum osmolarity, CPP goals and fluid balance • Hypotonic fluids, head of bed position, and arterial line • Venous thrombus protection, head of bed position, and pulmonary toilet

25. Correct Answer: B Mannitol is an osmotic diuretic. It works by increasing the amount of fluid excreted by the kidneys and helps the body decrease pressure in the brain and eyes. Drug Class: Osmotic Diuretic

26. A patient just arrived in the ICU after receiving tPA. The nurse assigned to this patient knows post infusion vital signs and neurological status needs to be checked: • 15 min x1 hr, q30 min x 2 hrs, then qhr x 16hrs, then every 4hrs • 15 min x2 hrs, q30min x 4hrs, q1hr x 16 hrs and then q 2-4 hrs • 15 min x 2 hrs, q30 min x 6 hrs, q 1hr x 16 hrs, and then q 2-4 hrs • 15 min x 2 hrs, q 30 min x 8 hrs, q 1hr x 16 hrs and then q 4hrs

27. Correct Answer: C Once tPA is administered the blood pressure should be maintained below 180/105 to decrease the risk of ICH. Avoid hypotension to maintain perfusion to the damaged area of the brain. Rapid neurological deterioration can indicate an ICH post infusion leading to the necessity of frequent neuro checks

28. A patient is admitted for observation following a mild subarachnoid hemorrhage. Throughout the night, the patient becomes increasingly confused and difficult to arouse but exhibits no focal neurological deficits. Which of the following is the most likely cause of this patient’s change in status? • Recurrent subarachnoid hemorrhage • New onset vasospasm • Subclinical seizures D. Communicating hydrocephalus

29. Correct Answer: D Cerebrospinal fluid (CSF) is normally produced in the ventricles by the choroid plexus at a rate of 20-25 ml/hr and is reabsorbed in the subarachnoid space by the arachnoid villi at the same rate. In the SAH patient, blood accumulation in the subarachnoid space limits the ability of the reabsorption of CHF, which leads to hydrocephalus. Symptoms of progressive communicating hydrocephalusinclude aslowly declining level of consciousness, without focal deficits.

30. An ischemic stroke patient is being given discharge instructions. The nurse knows that further instructions are needed when the patient makes the following statement “I will aim to keep my … • LDL cholesterol level greater than 130mg/dl • Blood pressure less than 120/80 • Body mass index no greater than 25 • HDL cholesterol level greater than 40mg/dl

31. Correct Answer: A Levels of LDL (low-density lipoprotein) cholesterol greater than 130mg/dl are linked to an increased risk for ischemic stroke. The American Heart/ StrokeAssociation recommended that LDL cholesterol levels be maintained at less than 100 mg/dl.

32. Answer the next 4 questions based on this scenario • A 75-year-old Caucasian female was found on the floor of her kitchen by her daughter at 10:00am. Her daughter called an ambulance and the woman was taken to the emergency room. In the ER the daughter states she talked to her mom on the phone at 08:15 and she was feeling fine. The patient presents with the following symptoms: • - paralysis of the right arm and leg-inability to answer questions but ability to understand what was said to her • VS are 178/100, 88, 20, 37.0 • Blood sugar: 100 • Pulse ox: 98% • PMHX: Hypertension, Dyslipidemia, Arthritis • Home Medications include: Lopressor 50 mg/dly, Zocor 20 mg every evening • Head CT was completed and was negative for any hemorrhage

33. ER nurse documents the Last Known Normal as: • 10:00 am • 08:15 pm • 06:00 am • 10:00 pm

34. Correct Answer: B To determine a patient’s eligibility for Tissue Plasminogen Activator (tPA) the time the patient was LAST KNOWN NORMAL time must be established. The window for most people is 3 hours. In some cases the window can be expanded to 4.5 hours.

35. Patient is determined a candidate for tPA. The nurse knows the dosage for tPA in an ischemic stroke is: • 0.5mg/kg administered over 2 hours • 0.9mg/kg with 10% bolus given first over 1 minute with the remainder administered over 24 hours • 0.9mg/kg with 10% bolus given over 1 minute with remainder administered over 1 hour • 0.3 mg/kg administered over 24 hours

36. Correct Answer: C • 0.9 mg/kg with 10% bolus given over 1 minute and then the remainder over 1 hour

37. The nurse knows that post tPA infusion B/P needs to remain below: • 130/80 • 185/110 • 190/100 • 180/105

38. Correct Answer: D • Pre infusion B/P should be maintained below 185/110 • Post infusion B/P needs o be maintained at or below 180/105

39. This patient is admitted to the ICU for the next 24 hours the nurse expects which of the following tests to be ordered as part of the stroke work-up: • Renal Ultrasound • Carotid Ultrasound • MRI of Cervical Spine • CTA of Chest

40. Correct Answer: B • The primary purpose of a carotid ultrasound is to test for narrowed carotid arteries. • This is completed to not only help determine the cause of this stroke but define secondary stroke prevention.

41. A subarachnoid hemorrhage patient has been admitted to the ICU and has a documented Hunt- Hess score of grade 5 and a Fisher grade of 4. The nurse knows the patients prognosis for recovery is: • Excellent • Poor • Good • Fair

42. Correct Answer: B ] Hunt and Hess Grading System Grade 1: Asymptomatic or mild headache Grade 2: Cranial nerve palsy or moderate to severe headache/nuchal rigidity Grade 3: Mild focal deficit, lethargy, or confusion Grade 4: Stupor and/or hemiparesis Grade 5: Deep coma, decerebrate posturing, moribund appearance The Fisher Grade (grades I-IV) assesses how much blood is on a CT scan. With both grading systems the higher the grade the poorer the prognisis

43. Lacunar strokes are characterized by: • Atherosclerotic plaque rupture in a cerebral vessel • Microthromboembolic vascular occlusion • Infarction of deep, small, penetrating arteries • Vascular leak in the circle of willis

44. Correct Answer: C 20% of strokes are the result of lacunar infactions which are small occlusions of tiny cerebral vessels in the deeper areas of the brain. Multiple tiny infarcts are common Frequently occur in persons with chronic hypertension and diabetes

45. Thank- you &Questions