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HESI RN EXIT CASE STUDY - STROKE, Exams of Study of Commodities

Case Western Reserve University (CWRU)Study of Commodities

HESI RN EXIT CASE STUDY - STROKE HESI RN EXIT CASE STUDY - STROKE HESI RN EXIT CASE STUDY - STROKE

Typology: Exams

2025/2026

Available from 04/05/2026

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HESI RN EXIT CASE STUDY - STROKE
1. The Emergency Department (ED) nurse completes the admission assess- ment. Mr.
Jones is alert but struggles to answer questions. When he attempts to talk, he slurs his
speech and appears very frightened. Which additional clinical manifestations should the
nurse expect to find if Mr. Jones' symptoms have 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 9 Mr.
Jones has a positive Babinski's reflex bilaterally
Mr. Jones is unable to verbalize responses to the nurse's questions
3. Due to his deteriorating condition, the neurologist is consulted to see Mr. Jones
immediately. The nurse suspects that Mr. Jones has probably suffered a right-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
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HESI RN EXIT CASE STUDY - STROKE

  1. 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 9 Mr. Jones has a positive Babinski's reflex bilaterally Mr. Jones is unable to verbalize responses to the nurse's questions
  2. 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

  1. 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
  2. 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."
  3. 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 that Mr. Jones is not a candidate for tissue plasminogen activator

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

  1. 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 30-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

in the right forearm. He also has an indwelling urinary catheter. The HCP prescribes bedrest and sitting upright in a chair 4 times a day.Which nursingdiagnosis has the highest priority ANS: Impaired swallowing

  1. Which nursing intervention should the nurse implement to address Mr.Jones' self-care deficit ANS: Use plate guards when Mr. Jones is eating
  2. Barry asks the nurse, "Why did my dad have this stroke? Does this meanI might have a stroke when I get older?" The nurse discusses the difference between modifiable and nonmodifiable risk factors for a stroke.Which con- ditions are considered a modifiable risk factor for a stroke ANS: High cholesterollevels Diet lifestyle Hx of atrial fibrillation
  3. Barry tells the nurse that he is going to go outside to smoke a cigarette and will only be gone for a few minutes. Which statement is warranted in thissituation ANS: "I should let you know that smoking is a strong risk factor for a stroke."
  4. Mr. Jones is experiencing homonymous hemianopsia as the result of his stroke. Which nursing intervention would the nurse implement to address: ANS: - Place objects needed for ADLs on right side of table
  5. Mr. Jones is experiencing pain in his left shoulder. The nurse is aware thatup to 70% of clients with a stroke experience severe pain in the shoulder that prevents them from 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

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.

  1. 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
  2. What action should the nurse implement to address this situation ANS: discusshow to use a communication board with Mr. Jones and Barry
  3. Which rehabilitation team member is responsible for evaluating Mr. Jones'dysphagia ANS: speech therapist
  4. Which intervention should the nurse prior to beginning a feeding ANS: ElevateHOB to 30 or 40 degrees
  5. 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
  6. Which intervention should the nurse implement first ANS: continue to stay atbedside and hold Barry's hand
  7. How should the nurse respond

ANS: "I am sorry, but I am unable to give you anyinformation."

  1. What actions should the nurse implement ANS: Explain that Mr. Jones can onlybe a tissue donor, not an organ donor Obtain necessary permits and notify the organ donor center
  2. Which action would be most important for the nurse to take in this situa-tion ANS: have clergy come pray
  3. How should the nurse respond ANS: "You seem really confused about what to do.Would you like to take about it?"