Coursepoint vSIM: William Edwards

The nurse is performing an initial neurological assessment on a patient who had a hemorrhagic stroke. Which assessment finding(s) needs to be reported? (Select all that apply.) A. Presence of ptosis B. Alert and oriented to person, place, time, and event C. Complaints of a headache D. Unable to move left leg and foot E. Pupils are sluggish

A, C, D & E

The nurse is receiving a report on a patient who had a hemorrhagic stroke. Which symptom would the nurse expect the patient to exhibit? A. Headache B. Weakness of the right arm C. Expressive aphasia D. Vision loss

Headache

William Edwards appears to have experienced _____________ based on his history of _____________.

Ischemic stroke; smoking

The nurse's responsibility for the patient receiving labetalol will be to monitor _______________ and administer the medication over ____________________ minutes to prevent orthostatic hypotension.

Blood pressure; 2

The nurse needs to administer a thrombolytic to a patient who is having a stroke. The nurse knows the thrombolytic therapy treatment window is how long? A. 9 hours B. 7 hours C. 5 hours D. 3 hours

3 hours

Which instruction(s) would the nurse give the William Edwards and his family about the initial dose of labetalol? (Select all that apply.) A. Rise slowly and avoid sudden position changes B. May use salt substitute C. Monitor blood glucose to prevent hypoglycemia D. Notify the nurse of abdominal pain E. Scalp tingling may occur F. May cause nocturia

A, C, & E

The patient is demonstrating receptive aphasia. The nurse knows to do which of the following? (Select all that apply.) A. Speak clearly and in an unhurried manner to assist the patient in forming the sounds. B. Speak clearly and in simple sentences; use gestures or pictures when able. C. Explore the patient's ability to write as an alternative means of communication. D. Explore the patient's ability to read as an alternative means of communication. E. Encourage patient to repeat sounds of the alphabet.

A & D Rationale: Nursing implications for a patient with receptive aphasia are the following: speak clearly and in an unhurried manner to assist the patient in forming the sounds and explore the patient's ability to read as an alternative means of communication. Nursing implications with expressive aphasia are the following: encourage patient to repeat sounds of the alphabet and explore the patient's ability to write as an alternative means of communication. Nursing implications for global aphasia are the following: speak clearly and in simple sentences; use gestures or pictures when able and establish alternative means of communication.

Which action(s) is priority when performing a stroke examination? (Select all that apply.) A. Check for airway patency B. Perform a rapid focused neurological assessment C. Check for bilateral carotid bruit D. Check vital signs E. Call radiology for a computed tomography (CT) scan F. Establish a timeline G. Check for reflexes

A, B, C, D, E, F, & G

Which clinical manifestation(s) if exhibited by William Edwards needs to be reported to the stroke team? (Select all that apply.) A. Blood pressure 184/98 mm Hg B. Swelling of the lower abdomen C. Blood glucose 120 mg/dL D. Able to shake hands E. Trouble speaking F. Difficulty following simple commands G. Smile is symmetrical

A, B, C, E, & F

After administering the labetalol, the nurse would identify which finding(s) as a sign that the medication has been effective? (Select all that apply.) A. Blood pressure 140/80 mm Hg B. Heart rate 70 C. Denial of a cough D. Blood glucose 106 mg/dL E. Skin turgor, non-tenting F. Bilateral lung sounds diminished but clear

A, B, D, & F

The nurse is caring for a patient who had a stroke. Which statement by the nurse regarding stroke causes is correct? A. 'An ischemic stroke can be caused by intracerebral hemorrhage.' B. "An ischemic stroke can be caused by a small artery thrombosis.' C. 'A hemorrhagic stroke can be caused by a cardiogenic embolism.' D. 'A hemorrhagic stroke can be caused by a large artery thrombosis.'

An ischemic stroke can be caused by a small artery thrombosis.'

Which condition is a complication of an ischemic stroke? A. Asterixis B. Atonic bladder C. Cerebral vasospasm D. Acute hydrocephalus

Atonic bladder

The nurse is to administer labetalol. The nurse knows to monitor for which side effect? A. Tachycardia B. Hyperkalemia C. Muscle cramps D. Dizziness

Dizziness

The nurse asks the patient, 'When did your symptoms begin?' The patient replies, 'bluueeeee.' The patient is demonstrating which type of communication dysfunction? A. Apraxia B. Global aphasia C. Expressive aphasia D. Receptive aphasia

Expressive aphasia