Page 2022 - Saunders Comprehensive Review For NCLEX-RN

A critical factor in the early intervention and treatment of stroke is the accurate

identification of stroke manifestations and establishing the onset of the manifestations.
Stroke screening scales may be used to identify stroke manifestations quickly.
Identification of the type of stroke occurring is critical in determining the appropriate
treatment, and this is usually done using imaging such as a CT scan.
1. Assessment findings depend on the area of the brain
affected; stroke scales such as the NIH Stroke Scale
(stroke.nih.gov/resources/scale.htm) may be used by
the health care facility for assessment.
2. Lesions in the cerebral hemisphere result in
manifestations on the contralateral side, which is the
side of the body opposite the stroke.

3. Airway patency is always a priority.

4. Pulse (may be slow and bounding)
5. Respirations (Cheyne-Stokes)
6. Blood pressure (hypertension)
7. Headache, nausea, and vomiting
8. Facial drooping
9. Nuchal rigidity
10. Visual changes
11. Ataxia
12. Dysarthria
13. Dysphagia
14. Speech changes
15. Decreased sensation to pressure, heat, and cold
16. Bowel and bladder dysfunctions
17. Paralysis
E. Aphasia
1. Expressive
a. Damage occurs in Broca’s area of the
frontal brain.
b. The client understands what is said but
is unable to communicate verbally.
2. Receptive
a. Injury involves Wernicke’s area in the
temporoparietal area.
b. The client is unable to understand the
spoken and often the written word.
3. Global or mixed: Language dysfunction occurs in
expression and reception.

4. Interventions for aphasia

a. Provide repetitive directions.
b. Break tasks down to 1 step at a time.
c. Repeat names of objects frequently
used.

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