SCRN Acute Care 4 — Questions and Answers
Question 1: A patient develops seizures 12 hours after an ischemic stroke. Which nursing intervention takes priority?
- Administer an antiepileptic drug as ordered and protect the airway (Correct answer)
- Restrain the patient to prevent injury
- Perform a 12-lead ECG immediately
- Increase the IV fluid rate
Correct 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.
Question 2: A patient with subarachnoid hemorrhage (SAH) from a ruptured aneurysm is at high risk for which serious delayed complication between days 4–14?
- Pulmonary embolism
- Cerebral vasospasm causing delayed ischemic neurological deficit (DIND) (Correct answer)
- Hyponatremia from SIADH only
- Hyperthyroidism
Correct 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.
Question 3: Nimodipine is routinely administered after subarachnoid hemorrhage. Its primary mechanism of benefit is:
- Prevention of hydrocephalus
- Reduction of vasospasm-related cerebral ischemia by blocking calcium channels (Correct answer)
- Systemic blood pressure reduction to prevent rebleeding
- Antiepileptic prophylaxis
Correct 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.
Question 4: 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?
- Continue the infusion and recheck in 6 hours
- Decrease the heparin rate per the protocol and notify the physician (Correct answer)
- Administer protamine sulfate immediately
- Stop the heparin and start warfarin
Correct 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.
Question 5: Which clinical finding in an acute stroke patient suggests hemorrhagic transformation of an ischemic infarct?
- Gradual improvement in motor strength over 24 hours
- Sudden neurological deterioration, new severe headache, and rising blood pressure (Correct answer)
- Stable NIHSS score over 48 hours
- Resolution of aphasia
Correct 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.
Question 6: A patient with a right hemispheric stroke demonstrates left-sided neglect. Which nursing strategy best addresses this deficit?
- Place all essential items on the patient's right side to promote use
- Approach the patient only from the left side
- Place essential items in the patient's left visual field and encourage scanning to the left (Correct answer)
- Restrict activities requiring bilateral visual attention
Correct 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.
Question 7: During IV tPA administration, a patient suddenly develops angioedema with tongue and lip swelling. What is the immediate nursing action?
- Slow the infusion rate and observe
- Stop the tPA infusion immediately and prepare to manage the airway (Correct answer)
- Administer diphenhydramine and continue the infusion
- Apply ice packs to the lips and continue monitoring
Correct 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.
SCRN Acute Care 4
A patient develops seizures 12 hours after an ischemic stroke.
Which nursing intervention takes priority?