NCLEX stroke assessment and care study guide
This study guide focuses on key concepts and nursing actions for assessing and managing stroke patients, essential for NCLEX preparation.
Quiz(32 questions)
1. What is the first action a nurse should take when a stroke is suspected?
Terms in this Study Set(32)
Stroke Assessment(16)
What is the acronym for stroke recognition?
FAST: Face drooping, Arm weakness, Speech difficulties, Time to call 911.
Which side of the body is affected in a right-sided stroke?
Left side of the body.
True or False: A stroke can be diagnosed using a CT scan.
True. A CT scan helps to identify hemorrhagic or ischemic strokes.
Fill in the blank: A sudden severe headache may indicate a ______ stroke.
hemorrhagic.
What is a common symptom of a left-sided stroke?
Right-sided weakness or paralysis.
Cause → Effect: What causes aphasia and what does it affect?
Cause: Damage to the language centers. Effect: Difficulty speaking or understanding language.
Name two key assessment techniques for stroke.
Neurological exam, GCS (Glasgow Coma Scale).
What is the purpose of the NIH Stroke Scale?
To assess the severity of a stroke and guide treatment.
Which facial feature is assessed for stroke during the FAST assessment?
Facial drooping.
True or False: Arm drift can indicate a stroke.
True. It tests for unilateral weakness.
What is the expected blood pressure range after a stroke?
Typically elevated to maintain cerebral perfusion.
What does slurred speech indicate during a stroke assessment?
Possible impairment in brain function, often linked to stroke.
Differentiate between ischemic and hemorrhagic stroke.
Ischemic: Blockage of blood flow. Hemorrhagic: Bleeding in the brain.
What is a common sign of a stroke in the limbs?
Weakness or paralysis, often unilateral.
Which assessment tool is crucial for initial stroke evaluation?
CT scan or MRI.
What should be done first if stroke symptoms are suspected?
Call emergency services immediately.
Stroke Care Management(16)
What is the priority nursing intervention for a stroke patient?
Ensure airway patency and monitor vital signs.
True or False: Patients with stroke should be placed in a supine position.
False. Position patient with the head elevated to reduce intracranial pressure.
Fill in the blank: The NIH Stroke Scale evaluates _____ severity.
stroke
What should be monitored for patients on anticoagulants after a stroke?
Watch for signs of bleeding; perform regular INR checks.
Cause → Effect: What happens if a stroke patient's blood pressure is too high?
Increased risk of hemorrhagic stroke.
Compare: Ischemic stroke vs. Hemorrhagic stroke causes.
Ischemic: Clots block blood flow. Hemorrhagic: Blood vessel rupture.
What is a key safety measure for stroke patients?
Implement fall precautions due to potential mobility issues.
List three common nursing interventions for stroke patients.
- Assess neurological status - Administer prescribed medications - Provide assistive devices
What dietary modification may be necessary post-stroke?
Swallowing assessments; possible need for thickened liquids.
True or False: Rehabilitation should start immediately after a stroke.
True. Early intervention improves outcomes.
What should be included in patient education post-stroke?
Lifestyle changes, medication adherence, and recognizing stroke symptoms.
What is the maximum time frame for administering tPA after a stroke?
Within 3-4.5 hours of symptom onset.
What is a common complication of a stroke requiring intervention?
Aspiration pneumonia; monitor swallow reflex.
Fill in the blank: Stroke patients should have blood glucose levels maintained between _____ and _____.
70 mg/dL and 180 mg/dL
What assessment tool measures stroke severity?
NIH Stroke Scale (NIHSS).
What is a key nursing intervention for stroke care?
Monitor neurological status regularly. - Perform frequent assessments using the NIH Stroke Scale. - Maintain airway patency. - Ensure safety measures are in place (e.g., fall precautions). - Administer medications as prescribed.
Questions in this Study Set(32)
1. What is the first action a nurse should take when a stroke is suspected?
2. What does the acronym FAST stand for in stroke recognition?
3. True or False: It is safe to give a stroke patient water immediately after their symptoms have resolved.
4. Which side of the body is typically affected in a left-sided stroke?
5. Fill in the blank: The primary purpose of the NIH Stroke Scale is to assess __________.
6. True or False: A stroke can be diagnosed using a CT scan.
7. Which nursing action is essential for a patient receiving tissue plasminogen activator (tPA)?
8. Fill in the blank: A sudden severe headache may indicate a ______ stroke.
9. Which of the following is a potential complication of a stroke?
10. What is a common symptom of a right-sided stroke?
11. What is the maximum time frame for administering tPA after stroke symptom onset?
12. What causes aphasia in stroke patients?
13. Which of the following dietary modifications may be necessary for stroke patients?
14. Which two assessment techniques are crucial for evaluating a stroke?
15. What should a nurse do to monitor for hypertension in a stroke patient?
16. What is the main purpose of the NIH Stroke Scale?
17. Which of the following is NOT a typical sign of a stroke?
18. During the FAST assessment, which facial feature is specifically evaluated?
19. What is a critical aspect of post-stroke rehabilitation?
20. True or False: Arm drift can indicate a stroke.
21. What should be included in patient education regarding stroke prevention?
22. What is the typical expected blood pressure change after a stroke?
23. Which assessment tool is commonly used to assess stroke severity?
24. What does slurred speech indicate during a stroke assessment?
25. Fill in the blank: Stroke patients should maintain blood glucose levels between ______ and ______.
26. Differentiate between ischemic and hemorrhagic stroke.
27. What nursing intervention is crucial for preventing falls in stroke patients?
28. What is a common physical sign of a stroke in the limbs?
29. True or False: Patients who have experienced a stroke are at increased risk for depression.
30. Which assessment tool is essential for the initial evaluation of a stroke?
31. What is the primary reason for monitoring vital signs closely in a stroke patient?
32. What is the first action to take if stroke symptoms are suspected?
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