case study stroke quizlet

Stroke Case Study (45 min)

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Mrs. Blossom is a 57-year-old female who presented to the Emergency Room with new onset Atrial Fibrillation with Rapid Ventricular Response (RVR). She is admitted to the cardiac telemetry unit after being converted to normal sinus rhythm with a calcium channel blocker (diltiazem). When you enter the room to assess Mrs. Blossom, her daughter looks at you concerned and says “mom’s acting kinda funny.”

What nursing assessments should be completed at this time?

• Full set of vital signs (Temp, HR, BP, RR, SpO2)
• Should probably get a 12-lead EKG
• Assess symptoms using PQRST or OLDCARTS

You assess Mrs. Blossom to find she has a left sided facial droop, slurred speech, and is unable to hold her left arm up for more than 3 seconds.

What is/are your priority nursing action(s) at this time?

• Call a Code Stroke (or whatever the equivalent is at your facility) to initiate response of the neurologist or Stroke team.
• Notify the charge nurse to help you obtain emergency equipment if you don’t already have it at the bedside to be prepared in case of emergency

What may be occurring in Mrs. Blossom?

• She may be having a stroke

You call a Code Stroke and notify the charge nurse for help. You obtain suction to have at bedside just in case. The neurologist arrives at bedside within 7 minutes to assess Mrs. Blossom. He notes her NIH Stroke Scale score is 32. He orders a STAT CT scan, which shows there is no obvious bleed in the brain.

What are the possible interventions for Mrs. Blossom at this time?

• Since there is no bleed evident on scan, Mrs. Blossom would qualify for a thrombolytic like tPA (alteplase) or for surgical intervention, as long as there are no contraindications

What are the contraindications for thrombolytics like tPA (alteplase)?

• Recent surgery, current or recent GI bleed within the last 3 months, excessive hypertension, evidence of cerebral hemorrhage

You administer tPA per protocol, initiate q15min vital signs and neuro checks. You stay with the patient to continue to monitor her symptoms.

What are possible complications of tPA administration? What should you monitor for?

• Bleeding, especially into the brain or a GI bleed
• She may bruise easily or bleed from IV sites or her gums
• Monitor for s/s bleeding or worsening stroke symptoms, which may indicate a hemorrhagic stroke has developed.

After 2 hours, Mrs. Blossom is showing signs of improvement. She is able to speak more clearly, though with a slight slur. She is still slightly weak on the left side, but is able to hold her arm up for 10 seconds now. Her NIHSS is now 6. Mrs. Blossom’s daughter asks you why this happened.

What would you explain has happened to Mrs. Blossom physiologically?

• Because of her new onset atrial fibrillation, the blood was likely pooling in her atria because they were just quivering and not contracting. When blood pools, it clots. When she was converted back into a normal rhythm and her atria began contracting again, that likely dislodged a clot, which went to her brain.
• The clot in her brain caused brain tissue to die → ischemic stroke.

Two days later, Mrs. Blossom has recovered fully. She will be discharged today on Clopidogrel and Aspirin, plus a calcium channel blocker,  with a follow up appointment in 1 week to see the neurologist.

What education topics should be included in the discharge teaching for Mrs. Blossom and her family?

• Anticoagulant therapy is imperative to prevent further clots from forming within Mrs. Blossom’s atria if she stays in Atrial Fibrillation.
• They should be taught the signs of a stroke (FAST) and call 911 if they notice them.
• They should be taught signs of Atrial Fibrillation with RVR and be sure to go to the hospital if this occurs – the patient is at higher risk for stroke.
• Medication instructions for calcium channel blockers and anticoagulants.

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Nursing Case Studies

This nursing case study course is designed to help nursing students build critical thinking.  Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process.  To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy  to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs.  If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding.  In the end, that is what nursing case studies are all about – growing in your clinical judgement.

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Stroke (CVA) NCLEX Questions

Stroke (CVA) NCLEX practice questions  for nursing students. A stroke is where there is decreased blood flow to brain cell tissue. This can be due to either a blockage or ruptured blood vessel.

In the previous NCLEX review , I explained about other neurological disorders, so be sure to check those reviews out.

As the nurse, it is important to know the pathophysiology of stroke, the types of drugs used to treat this condition, risk factors, signs and symptoms, and the nursing interventions.

Don’t forget to watch the lecture on stroke before taking the quiz.

Stroke NCLEX Questions

This quiz will test your knowledge on stroke (CVA) in preparation for the NCLEX exam.

A. Ischemic thrombosis

B. Ischemic embolism

C. Hemorrhagic

D. Ischemic stenosis

A. A 65 year old male patient with carotid stenosis.

B. A 89 year old female with atherosclerosis.

C. A 88 year old male with uncontrolled hypertension and a history of brain aneurysm repair 2 years ago.

D. A 55 year old female with atrial flutter.

A. TIAs are caused by a temporary decrease in blood flow to the brain.

B. TIAs produce signs and symptoms that can last for several weeks to months.

C. A TIAs is a warning sign that an impending stroke may occur.

• D. TIAs don't require medical treatment.

A. Frontal lobe

B. Occipital lobe

C. Parietal lobe

D. Temporal

A. Vision problems

B. Balance impairment

C. Language difficulty

D. Impaired short-term memory

A. Brain stem

B. Hippocampus

D. Occipital lobe

A. Right side hemiplegia

B. Confusion on date, time, and place

D. Unilateral neglect

E. Aware of limitations

F. Impulsive

G. Short attention span

H. Agraphia

B. Denial about limitations

C. Impaired math skills

D. Issues with seeing on the right side

E. Disoriented

F. Depression and anger

G. Impulsive

B. Family history

C. Advanced age

E. Sedentary lifestyle

• A. Expressive; Wernicke's area
• B. Receptive, Broca's area

C. Expressive; hippocampus

• D. Receptive; Wernicke's area
• A. Fill in the words for the patient they can't say.
• B. Don't repeat questions.

C. Ask questions that require a simple response.

D. Use a communication board.

E. Discourage the patient from using words.

A. Dysarthria

D. Dysphagia

A. The patient is unable to read.

B. The patient has limited vision in half of the visual field.

C. The patient is unable to wink or move his arm to scratch his skin.

• D. The patient doesn't recognize a pencil or television.

A. Agraphia

C. Hemianopia

A. Hemianopia

B. Opticopsia

D. Dysoptic

A. Wearing anti-embolism stockings daily

B. Consume soft foods and tuck in chin while swallowing

C. Scanning the room from side to side frequently

D. Muscle training

A. No stroke symptoms

B. Severe stroke symptoms

C. Mild stroke symptoms

D. Moderate stroke symptoms

A. 6 hours after the onset of stroke symptoms

B. 3 hours before the onset of stroke symptoms

C. 3 hours after the onset of stroke symptoms

D. 12 hours before the onset of stroke symptoms

A. A patient with a CT scan that is negative.

B. A patient whose blood pressure is 200/110.

C. A patient who is showing signs and symptoms of ischemic stroke.

D. A patient who received Heparin 24 hours ago.

• A. Keep the head of bed less than 30'.

B. Check for pouching of food in the right cheek.

C. Prevent aspiration by thinning the liquids.

D. Have the patient extend the neck upward away from the chest while eating.

A. Remind the patient to use and touch both sides of the body daily.

B. Offer the patient a soft mechanical diet with honey thick liquids.

C. Ask direct questions that require one word responses.

D. Offer the bedpan and bedside commode every 2 hours.

1. A patient is admitted with uncontrolled atrial fibrillation. The patient’s medication history includes vitamin D supplements and calcium. What type of stroke is this patient at MOST risk for?

The answer is B. If a patient is in uncontrolled a-fib they are at risk for clot formation within the heart chambers. This clot can leave the heart and travel to the brain. Hence, an ischemic embolism type stroke can occur. An ischemic thrombosis type stroke is where a clot forms within the artery wall of the neck or brain.

2. Which patient below is at most risk for a hemorrhagic stroke?

The answer is C. A hemorrhagic stroke occurs when bleeding in the brain happens due to a break in a blood vessel. Risk factors for a hemorrhagic stroke is uncontrolled hypertension, history of brain aneurysm, old age (due to aging blood vessels.) All the other options are at risk for an ischemic type of stroke.

3. You’re educating a patient about transient ischemic attacks (TIAs). Select all the options that are incorrect about this condition:

D. TIAs don’t require medical treatment.

The answers are B and D. Options A and C are CORRECT statements about TIAs. However, option B is wrong because TIAs produce signs and symptoms that can last a few minutes to hours and resolve (NOT several weeks to months). Option D is wrong be TIAs do require medical treatment.

4. A patient who suffered a stroke one month ago is experiencing hearing problems along with issues learning and showing emotion. On the MRI what lobe in the brain do you expect to be affected?

The answer is D. The temporal lobe is responsible for hearing, learning, and feelings/emotions.

5. A patient’s MRI imaging shows damage to the cerebellum a week after the patient suffered a stroke. What assessment findings would correlate with this MRI finding?

The answer is B. The cerebellum is important for coordination and balance.

6. A patient is demonstrating signs and symptoms of stroke. The patient reports loss of vision. What area of the brain do you suspect is affected based on this finding?

The answer is D. The occipital lobe is responsible for vision and color perception.

7. A patient has right side brain damage from a stroke. Select all the signs and symptoms that occurs with this type of stroke:

The answers are B, D, F, and G. Patients who have right side brain damage will have LEFT side hemiplegia (opposite side), confused on date, time, and place, unilateral neglect (left side neglect), DENIAL about limitations, be impulsive, and have a short attention span. Agraphia, right side hemiplegia, aware of limitations, and aphasia occur in a LEFT SIDE brain injury.

8. You’re educating a group of nursing students about left side brain damage. Select all the signs and symptoms noted with this type of stroke:

The answers are A, C, D, F, and H. Patients who have left side brain damage will have aphasia, be AWARE of their limitations, impaired math skills, issues with seeing on the right side, no deficit in memory, depression/anger, cautious, and agraphia. All the other options are found in right side brain injury.

9. During discharge teaching for a patient who experienced a mild stroke, you are providing details on how to eliminate risk factors for experiencing another stroke. Which risk factors below for stroke are modifiable?

The answers are A, D, and E. These risk factors are modifiable in that the patient can attempt to change them to prevent another stroke in the future. The other risk factors are NOT modifiable.

10. Your patient who had a stroke has issues with understanding speech. What type of aphasia is this patient experiencing and what area of the brain is affected?

A. Expressive; Wernicke’s area

B. Receptive, Broca’s area

D. Receptive; Wernicke’s area

The answer is D.

11. Your patient has expressive aphasia. Select all the ways to effectively communicate with this patient?

A. Fill in the words for the patient they can’t say.

B. Don’t repeat questions.

The answers are C and D. Patients with expressive aphasia can understand spoken words but can’t respond back effectively or at all. Therefore be patient, let them speak, be direct and ask simple questions that require a simple response, and communicate with a dry erase board etc.

12. While conversing with a patient who had a stroke six months ago, you note their speech is hard to understand and slurred. This is known as:

The answer is A.

13. You’re reading the physician’s history and physical assessment report. You note the physician wrote that the patient has apraxia. What assessment finding in your morning assessment correlates with this condition?

D. The patient doesn’t recognize a pencil or television.

The answer is C.

14. You need to obtain informed consent from a patient for a procedure. The patient experienced a stroke three months ago. The patient is unable to sign the consent form because he can’t write. This is known as what:

15. You’re assessing your patient’s pupil size and vision after a stroke. The patient says they can only see half of the objects in the room. You document this finding as:

16. A patient who has hemianopia is at risk for injury. What can you educate the patient to perform regularly to prevent injury?

The answer is C. Hemianopia is limited vision in half of the visual field. The patient needs to scan the room from side to side to prevent injury.

17. You receive a patient who is suspected of experiencing a stroke from EMS. You conduct a stroke assessment with the NIH Stroke Scale. The patient scores a 40. According to the scale, the result is:

The answer is B. Scores on the NIH stroke scale range from 0 to 42, with 0 (no stroke symptoms) and 21-42 (severe stroke symptoms).

18. In order for tissue plasminogen activator (tPA) to be most effective in the treatment of stroke, it must be administered?

The answer is C. tPa dissolves the clot causing the blockage in stroke by activating the protein that causes fibrinolysis. It should be given within 3 hours after the onset of stroke symptoms. It can be given 3 to 4.5 hours after onset IF the patient meets strict criteria. It is used for acute ischemia stroke, NOT hemorrhagic!!

19. Which patients are NOT a candidate for tissue plasminogen activator (tPA) for the treatment of stroke?

The answers are B and D. Patients who are experiencing signs and symptoms of a hemorrhagic stroke, who have a BP for >185/110, and has received heparin or any other anticoagulants etc. are NOT a candidate for tPA. tPA is only for an ischemic stroke.

20. You’re assisting a patient who has right side hemiparesis and dysphagia with eating. It is very important to:

A. Keep the head of bed less than 30′.

The answer is B. Because the patient has weakness on the right side and dysphagia the nurse should regularly check for pouching of food in the right cheek. Pouching of food in the cheek can lead to aspiration or choking. The HOB should be >30′, liquids thickened per MD order, and the patient should tuck in the chin to the chest while swallowing.

21. A patient has experienced right side brain damage. You note the patient is experiencing neglect syndrome. What nursing intervention will you include in the patient’s plan of care?

The answer is A. It is important to watch for neglect syndrome. This tends to happen in right side brain damage. The patient ignores the left side of the body in this condition. The nurse needs to remind the patient to use and touch both sides of the body daily and that the patient must make a conscious effort to do so.

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Review Question Answers

What acronym is used to to help identify strokes?

Answer: F.A.S.T – Facial droop, arm drop, speech problems, time. This acronym is universally used to easily teach people how to recognize a stroke. The other acronyms are not used to help people identify strokes.

What are some risk factors for having a stroke? Select all that apply.

Answer: Uncontrolled hypertension, and smoking. Uncontrolled hypertension can damage blood vessels and cause vasoconstriction making it more likely for a clot to form and obstruct the blood flow to the brain. Smoking can also damage blood vessels and cause vasoconstriction, smoking can increase the risk of stroke by up to 50%. Physical activity decreases, not increases, the risk of stroke. Drinking 8 glasses of water is healthy for the body and does not cause an increased risk of strokes.

What is the difference between a TIA and a stroke?

Answer: While both are caused by a lack of blood flow to one or more areas of the brain and they share many of the same clinical manifestations, the symptoms of a TIA resolve in an hour or less.

What is the postictal phase?

Answer: The postictal phase is the period of time immediately following an epileptic seizure and may last from a few minutes to hours. Clinical manifestations often mimic a stroke. Patient history and testing is needed to differentiate the two.

What is the difference between a thrombotic stroke and an embolic stroke?

Answer: A thrombotic stroke is due to thrombi formed in the intracranial vessels or vessels that feed the brain. An embolic stroke happens when fragments break from a thrombus that is formed outside of the brain.

What are two types of hemorrhages that can occur in a hemorrhagic stroke?

Answer: Subarachnoid & intracerebral. Subarachnoid is a bleed that occurs between the brain and the dura while an intracerebral bleed occurs actually in the brain parenchyma. The other answers are classified as ischemic strokes.

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