Stroke, seizure, and increased intracranial pressure nursing assessment priorities on the medical-surgical floor, distinct from the ICU neuro-monitoring deck.
35 cards · basic cards · AI-written, checked twice. Edit anything.
- What does the FAST acronym assess for in suspected stroke?
- Face drooping, Arm weakness, Speech difficulty, Time to call for help
- What is the standard time window for giving tPA after ischemic stroke symptom onset?
- Within 3 to 4.5 hours of symptom onset
- What is the priority nursing assessment for a patient with sudden neurological symptoms?
- Airway, breathing, and circulation, followed by a neurologic assessment
- What causes an ischemic stroke?
- A blood clot blocking blood flow to part of the brain
- What causes a hemorrhagic stroke?
- Bleeding into or around brain tissue from a ruptured blood vessel
- Why must a CT scan be done before giving tPA?
- To rule out hemorrhagic stroke, since tPA can worsen bleeding
- What should a nurse do before giving a stroke patient anything by mouth?
- Perform a swallow screening to check for dysphagia
- What position reduces aspiration risk during a stroke patient's swallow evaluation?
- Upright sitting position (high Fowler's)
- Why is blood pressure typically allowed to run higher than normal right after an acute ischemic stroke?
- To maintain cerebral perfusion to the at-risk brain tissue (permissive hypertension)
- If a stroke damages the left side of the brain, which side of the body is typically weak?
- The right side of the body
- What is expressive aphasia?
- Difficulty producing or forming speech despite understanding language
- What is receptive aphasia?
- Difficulty understanding spoken or written language
- What is the first nursing priority when a patient begins having a seizure?
- Protect the patient from injury and maintain a patent airway
- During a seizure, why should a nurse never restrain a patient's movements?
- Restraining can cause fractures or other injuries
- During a seizure, why should a nurse never place anything in the patient's mouth?
- It can cause airway obstruction or injury to the teeth and mouth