vSim Fundamentals | Vernon Russell (Stroke, Aspiration Risks, Final vSim)

The nurse is assessing Mr Russell's pupillary response. List the steps of the procedure in the order they should be performed.

1. Darken the room 2. Ask the patient to look straight ahead 3. Bring the penlight in from the side of the patient's face and briefly shine light on pupil 4. Observe pupil's reaction 5. Repeat procedure with the same eye, but this time, observe the other eye 6. Repeat the procedure with the other eye

The nurse is evaluating a patient's neurological status. What should the nurse include when assessing a patient's level of awareness?

When assessing level of awareness, the nurse should assess Time (e.g., what is today's date? what day of the week is it?; Place (e.g., Where are you now? What is the name of this city?); and Person (e.g., What is your name? How old are you?). If the patient is oriented to time, place, and person, the nurse would document that the patient is alert and oriented x 3.

Which observation supports the possibility that a patient who has experienced a stroke has aspirated? (Select all that apply)

a) Coughing c) Hoarseness e) Regurgitation into the mouth

Neuro Check

a. LOC b. Sensory perception d. Memory e. Cranial Nerves

The nurse is calling in report to the provider using the SBAR format. Which statement by the nurse would be the "S" when using this reporting technique?

c. The patient began coughing when eating breakfast this morning

A patient has been admitted with a diagnosis of stroke, and the nurse has received orders to hold warfarin until lab results are received. What lab results does the nurse anticipate reviewing prior to administering this medication?

PT/INR

The nurse is assessing a patient using the Glasgow Coma Scale. Which of the following are components of that scale? (select all that apply)

a. Motor response b. Eye opening e. Verbal response

Mr. Russell has an order for vital signs and neurochecks every four hours. Which assessment findings, if made by the nurse, would indicate potential neurologic compromise? (select all that apply.)

a. Unequal pupils c. Decreasing level of consciousness Rationale: Mr. Russell was already experiencing left-sided weakness and difficulty swallowing following the stroke. D/t the left-sided weakness, an unsteady gait would be expected.

Mr. Russell experienced dysphagia and mild left-sided weakness following his stroke. For which additional symptoms of stroke should the nurse assess? (select all that apply)

a. Urinary incontinence b. Communication difficulties d. Sensory deficits

The nurse is caring for a stroke patient with mild dysphagia. What would be an appropriate nursing intervention for this patient in order to minimize risk for injury? (select all that apply.)

c. Educating the patient about the importance of alternating liquids and solids d. Providing a 30-minute rest period prior to mealtimes e. Positioning patient upright in chair if not contraindicated