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HESI RN EXIT CASE STUDY - STROKE
- The Emergency Department (ED) nurse completes the admission assess- ment. Mr. Jones is alert but struggles to answer questions. When he attemptsto talk, he slurs his speech and appears very frightened. Which additional clinical manifestations should the nurse expect to find if Mr. Jones' symptomshave been caused by a stroke ANS: carotid bruit
elevated BP hyporeflexic DTR
2. Which assessment finding warrants immediate intervention by the RN? ANS: (Select all): Mr. Jones' Glasgow Coma Scale (GCS) score changes from 12 to 9Mr. Jones has a positive Babinski's reflex bilaterally Mr. Jones is unable to verbalize responses to the nurse's questions
- Due to his deteriorating condition, the neurologist is consulted to see Mr. Jones immediately.The nurse suspects that Mr. Jones has probably suffered aright-sided stroke. Which clinical manifestations further support this assess-ment ANS: increased distractibility
visual deficit on left side spatial-perceptual deficits paresthesia on left side
4. The neurologist writes a diagnosis of "suspected stroke" and prescribes a computed tomography (CT) scan without contrast STAT. Which interventionshould the nurse implement when preparing Mr. Jones and his son for thisprocedure ANS: Explain procedure requires client to lie completely still
- The neurologist also prescribes a magnetic resonance imaging (MRI) ofthe head STAT. Which data warrants immediate intervention by the nurse concerning this diagnostic test ANS: left hip replacement
- Which explanation by the nurse is the most therapeutic response ANS: "Your father has had a stroke, and the blood supply to the brain has been compromised."
- Barry is visibly upset and states, "Dad has been fine all week. We even wentout to dinner. I love him so much and I am scared." How should the nurse respond ANS: "I know this is scary for you. Would you like to sit and talk?" 8. The neurologist diagnoses an ischemic right-sided stroke. The neurologistdetermines
(tPA). Enoxaparin 1 mg/kg subcutaneously every 12 hours is prescribed.Mr. Jones weighs 170 pounds. How many mg of enoxaparin will the nurse admin-ister in each dose? (Enter the numerical value only. If rounding is required, round to the whole number) ANS:.: 77
170/2.2= 77.
- With a diagnosis of a stroke, which priority intervention should the nurseinclude in Mr. Jones' plan of care ANS: monitor glucose daily
elevate HOB assess neuro status every hour monitor PTT daily
- The nurse continues to monitor Mr. Jones' condition closely.Which findingwould require immediate intervention by the nurse ANS: Serum glucose is 150
potassium is 3.
pulse ox has been 90% for the past two hours
- Over the next 24 hour, Mr. Jones' SaO 2 , potassium level, and telemetry readings are
within normal limits for his age, but his cardiac output decreases.The HCP needs to be notified regarding decreased cardiac output to decide whether to initiate IV fluid if hypovolemia is an issue and to determine other medical interventions.Which nursing interventions would be priority at this time ANS: Monitor LOC
Monitor intake & output hourly Monitor capillary refill every 2 to 4 hours Monitor pulse oximetry
- As the nurse assesses Mr. Jones, Barry asks, "Why isn't my dad a candi-date for thrombolytic therapy?" How should the nurse respond to Barry ANS: "Heis not a candidate because of therapeutic time constraints related to this medication." 13. Mr. Jones spends 3 days in the Neuro Intensive Care Unit. Once stabilized,he is transferred to a 3 0 - bed medical unit. Mr. Jones has left-sided paralysis,facial drooping with dysphagia, left visual field deficit and aphasia. His IV fluids are discontinued, but he continues with a 20 gauge saline lock, now
learning new skills. Shoulder function helps clients achieve balance, perform transfer skills, and participate in self-care activi- ties.Which intervention should the nurse implement when addressing this condition ANS: Instruct Mr. Jones to clasp the left hand with the right hand and raise both hands above the head.
- How should the nurse respond ANS: "That procedure is only done with smallstrokes, not like the one your dad had."
- Which nursing care task should the nurse delegate to the UAP? (Select all the apply.): Take Mr. Jones' vital signs Give Mr. Jones a bed bath and change the bed linensMeasure Mr. Jones' intake and output each shift (I&O) 21. A physical therapist (PT) places a gait belt on Mr. Jones and assists himwith ambulation from the bed to the chair. As he gets up out of the bed, Mr.
Jones says he is dizzy and begins to fall. The PT carefully allows him to fall back to the bed and notifies the primary nurse. Which written documentationshould the nurse put in the client's record ANS: PT reported that client stated he feltdizzy and was lowered to the bed assisted by the PT using a gait belt.
- Which interventions should the nurse implement to prevent joint deformi-ties ANS: Apply splints the arms and legs at night
Place the elbow higher than the shoulder and the wrist higher than the elbow on theaffected side
Place in prone position for 15 min for at least 4 times a day
- What action should the nurse implement to address this situation ANS: discusshow to use a communication board with Mr. Jones and Barry
- Which rehabilitation team member is responsible for evaluating Mr. Jones'dysphagia ANS: speech therapist
- Which intervention should the nurse prior to beginning a feeding ANS: ElevateHOB to 30 or 40 degrees
- The HCP orders 360 mL of liquid nourishment diluted with one can of water to be infused over 8 hours. The feeding will be administered through aninfusion pump, which infuses in mL/hr. At what rate would the nurse set the infusion pump? (Enter numerical value only. If rounding is necessary, roundto the whole number.): 75
360 ml + 240 ml (8 oz x 30 ml)= 600 ml/8 hrs= 75 ml/hr
