Acute Care Flashcards

A patient develops seizures 12 hours after an ischemic stroke. Which nursing intervention takes priority?

Answer: Administer an antiepileptic drug as ordered and protect the airway

Seizure management priorities are airway protection and prompt administration of ordered antiepileptics to terminate the seizure and prevent recurrence.

A patient with subarachnoid hemorrhage (SAH) from a ruptured aneurysm is at high risk for which serious delayed complication between days 4–14?

Answer: Cerebral vasospasm causing delayed ischemic neurological deficit (DIND)

Cerebral vasospasm peaks between days 4 and 14 after SAH and can cause delayed ischemic injury; nimodipine is given prophylactically to reduce this risk.

Nimodipine is routinely administered after subarachnoid hemorrhage. Its primary mechanism of benefit is:

Answer: Reduction of vasospasm-related cerebral ischemia by blocking calcium channels

Nimodipine is a calcium channel blocker that reduces the severity of neurological deficits from vasospasm-induced ischemia following SAH.

A stroke patient on heparin infusion for cardioembolic stroke has a PTT result of 220 seconds (therapeutic range: 60–100 seconds). What is the nurse's priority action?

Answer: Decrease the heparin rate per the protocol and notify the physician

A supratherapeutic PTT increases hemorrhagic transformation risk; the heparin rate must be reduced per weight-based protocol and the physician notified.

Which clinical finding in an acute stroke patient suggests hemorrhagic transformation of an ischemic infarct?

Answer: Sudden neurological deterioration, new severe headache, and rising blood pressure

Hemorrhagic transformation typically presents with abrupt neurological worsening, severe headache, and hypertension as blood extravasates into the infarct zone.

A patient with a right hemispheric stroke demonstrates left-sided neglect. Which nursing strategy best addresses this deficit?

Answer: Place essential items in the patient's left visual field and encourage scanning to the left

Rehabilitation for hemispatial neglect involves placing stimuli in the neglected field and training the patient to consciously scan toward the affected side.

During IV tPA administration, a patient suddenly develops angioedema with tongue and lip swelling. What is the immediate nursing action?

Answer: Stop the tPA infusion immediately and prepare to manage the airway

Orolingual angioedema is a life-threatening complication of alteplase; the infusion must be stopped immediately and airway management initiated.