N136 Week 4 - Stroke
Question 12 of 31 As the nurse assesses client, his son asks, "Why isn't my dad a candidate for thrombolytic therapy?" How should the nurse respond? "I think that is something you should discuss with your father's HCP." "He is not a candidate because of therapeutic time constraints related to this medication." "Thrombolytic therapy is usually not administered to anyone older than 65 years." "Since your father was alert on admission, he is not a candidate to receive this medication."
"He is not a candidate because of therapeutic time constraints related to this medication." "I think that is something you should discuss with your father's HCP." The nurse has the knowledge and ability to answer the question. "He is not a candidate because of therapeutic time constraints related to this medication." Thrombolytic therapy is contraindicated in clients with symptom onset longer than 3 hours prior to admission. Client had symptoms for 24 hours before being brought to the ED. Linton, A., Matteson, M. (2020). Medical-Surgical Nursing. (7th edition). St. Louis, Missouri. Elsevier. Pg. 406. "Thrombolytic therapy is usually not administered to anyone older than 65 years." This is false information. There are certain criteria when thrombolytic therapy would not be administered, but age is not one of them. "Since your father was alert on admission, he is not a candidate to receive this medication." This is false information. There are certain criteria when thrombolytic therapy would not be administered, but being alert is not one of them.
The telephone at client's bedside starts ringing. The nurse answers the phone. The caller is client's pastor, asking how he is doing. Question 28 of 31 How should the nurse respond? "I am so sorry, but he just passed away." "I will have his call you at a later time." "I am sorry, but I am unable to give you any information." "Let me have your number so I can call you back in a few minutes."
"I am so sorry, but he just passed away." This violates the Health Insurance Portability and Accountability Act (HIPAA) and the client's right to confidentiality. "I will have his call you at a later time." The nurse should not speak for the son, as he may not want to call people back at this time. "I am sorry, but I am unable to give you any information." According to the Health Insurance Portability and Accountability Act (HIPAA), the client has a right to confidentiality. The nurse cannot give any information to someone who does not have a "need to know." Potter, P., Perry, A., Stockert, P., Hall, A. (2019). Essentials for Nursing Practice. (9th edition). St. Louis, Missouri. Elsevier. Pg. 67. "Let me have your number so I can call you back in a few minutes." The nurse cannot give any information to client's pastor.
Question 16 of 31 Client's son 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 this situation, since the son inquired about risk factors for stroke? "I should also let you know that smoking is a strong risk factor for a stroke." "Ok, I will be sure your father is well taken care of in your absence." "Make sure you smoke in the smoking area only. The hospital has strict rules." "Does smoking help you cope with stressful situations?"
"I should also let you know that smoking is a strong risk factor for a stroke." The nurse should teach the son that smoking is a modifiable risk factor that could increase his chance of having a stroke. Smoking also increases the risk for hypertension, which is a risk factor for a stroke. Linton, A., Matteson, M. (2020). Medical-Surgical Nursing. (7th edition). St. Louis, Missouri. Elsevier. Pg. 398. "Ok, I will be sure your father is well taken care of in your absence." This response enables, and possibly encourages, the son to continue smoking. "Make sure you smoke in the smoking area only. The hospital has strict rules." This response enables, and possibly encourages, the son to continue smoking. "Does smoking help you cope with stressful situations?" This information may be a basis for future education, but it does not address the son's decision to go out and smoke.
The son tells the nurse, "One of the people in the waiting room was telling me about an operation that her mother had to prevent a stroke. Do you know anything about that?" Question 19 of 31 How should the nurse respond? "I think that lady misunderstood her mother's surgical procedure." "That procedure is only done with small strokes, not like the one your dad had." "Yes, it is a carotid endarterectomy, and your father may be able to have one." "That is a question you should ask your dad's HCP."
"I think that lady misunderstood her mother's surgical procedure." This statement does not address the son's concern. "That procedure is only done with small strokes, not like the one your dad had." This surgery is indicated for clients with symptoms of transient ischemic attack (TIA), or mild stroke, found to be due to severe carotid artery stenosis or moderate stenosis with other significant risk factors. Linton, A., Matteson, M. (2020). Medical-Surgical Nursing. (7th edition). St. Louis, Missouri. Elsevier. Pg. 399. "Yes, it is a carotid endarterectomy, and your father may be able to have one." This is not correct information. "That is a question you should ask your dad's HCP." The nurse has the knowledge and responsibility to answer this question, even if the son chooses to ask the HCP about it later.
Client's son is crying quietly while sitting in his room. He tells the nurse that his mother was buried in the local cemetery. He states that prior to his mother's death, his parents had discussed cremation and having his ashes scattered in the city rose garden that they loved so much. He wants to bury his father beside his mother in the local cemetery and tells the nurse, "I just don't know what I should do." Question 31 of 31 How should the nurse respond? "You should do what your father wanted." "I will contact your pastor and you can ask him what you should do." "You seem really confused about what to do. Would you like to talk about it?" "Isn't cremation cheaper than a funeral?"
"You should do what your father wanted." This is advising and is not a therapeutic response. "I will contact your pastor and you can ask him what you should do." This is "passing the buck" and is not a therapeutic response. "You seem really confused about what to do. Would you like to talk about it?" This is a therapeutic response and addresses the son's feelings. Potter, P., Perry, A., Stockert, P., Hall, A. (2019). Essentials for Nursing Practice. (9th edition). St. Louis, Missouri. Elsevier. Pg. 191-192. Cooper, K., Gosnell, K. (2019). Foundations of Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 68. "Isn't cremation cheaper than a funeral?" This is not an appropriate question for the nurse to ask.
Question 26 of 31 Fill in the blankThe HCP orders 360 mL of liquid nourishment diluted with one 8 ounce can of water to be infused over 8 hours. The feeding will be administered through an infusion pump, which infuses in mL/hr. At what rate would the nurse set the infusion pump? (Enter numerical value only. If rounding is necessary, round to the whole number.) (Enter numerical value only. If rounding is necessary, round to the whole number.) mL/hour
75
Section 11 Management The nurse on the day shift is caring for client and four other medical clients. There are two unlicensed assistive personnel (UAP) on the unit assisting with the client care. Question 20 of 31 Which nursing care task should the nurse delegate to the UAP? (Select all that apply. One, some or all options may be correct.) Select all that apply Assist client with his breakfast. Assist client in getting in the chair. Take client's vital signs. Give client a bed bath and change the bed linens. Measure client's intake and output each shift (I&O).
Assist client with his breakfast. Since client has dysphagia, the nurse should not delegate this high-risk task to the UAP. Assist client in getting in the chair. This task should be performed by the physical therapist. Take client's vital signs. The UAP can assist with activities of daily living (ADL), vital signs, and measurements such as weights and intake & output (I&O). KCooper, K., Gosnell, K. (2019). Foundations of Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 192. Give client a bed bath and change the bed linens. The UAP can assist client with bathing and then change the bed linens. This task does not require professional judgment or expertise. Cooper, K., Gosnell, K. (2019). Foundations of Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 192. Measure client's intake and output each shift (I&O). This task can be delegated to the UAP to measure intake and output. This task does not require professional judgement or expertise. Cooper, K., Gosnell, K. (2019). Foundations of Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 192.
Section 14 Safe and Effective Care Environment Client appears depressed, and the son reports that his father seems to have lost all hope. He reminds the staff that his father has a Living Will and a Do Not Resuscitate (DNR), or Allow Natural Death (AND) order. Client has a Durable Power of Attorney for Health Care that was signed more than 2 years ago. Two weeks later, the son is sitting at the bedside when client starts to gasp for air. The son rings the call light and also yells for help. When the nurse arrives, client is not breathing. The nurse assesses his apical pulse but cannot hear anything. Question 27 of 31 Which intervention should the nurse implement first? Call the rapid response team (RRT). Continue to stay at client's bedside and offer the son support. Provide two rescue breaths and call a "CODE." Ask son to leave the room while the nurse assess the apical pulse.
Call the rapid response team (RRT). This is not the correct action to take in this situation. Continue to stay at client's bedside and offer the son support. The client has a DNR, order, therefore, no action should be taken. Providing support to the son as his father dies is the best nursing action in this situation. Linton, A., Matteson, M. (2020). Medical-Surgical Nursing. (7th edition). St. Louis, Missouri. Elsevier. Pg. 324-325. Provide two rescue breaths and call a "CODE." This is not the correct action in this situation. Ask son to leave the room while the nurse assess the apical pulse. This is not the correct action in this situation.
Question 21 of 31 A physical therapist (PT) places a gait belt on client and assists him with ambulation from the bed to the chair. As he gets up out of the bed, client 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 documentation should the nurse put in the client's record? Client experienced orthostatic hypotension when getting out of bed. PT reported that client stated he felt dizzy and was lowered to the bed assisted by the PT using a gait belt. PT notified the primary nurse that the client could not ambulate at this time because of dizziness. Client had difficulty ambulating from the bed to the chair when accompanied by the PT, variance report completed.
Client experienced orthostatic hypotension when getting out of bed. The nurse is making an assumption that the dizziness was caused by orthostatic hypotension. PT reported that client stated he felt dizzy and was lowered to the bed assisted by the PT using a gait belt. This documentation provides the factual data of the events that occurred. Cooper, K., Gosnell, K. (2019). Foundations of Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 43. PT notified the primary nurse that the client could not ambulate at this time because of dizziness. Not all of the pertinent facts are included in this documentation. Client had difficulty ambulating from the bed to the chair when accompanied by the PT, variance report completed. A variance report should never be documented in the client's record.
Section 13 Physiologic Integrity Client has been unable to swallow effectively and is still at risk for choking. The nurse notes that he has not been able to meet his nutritional needs and has lost 10 lbs (4.5 kg) over the past weeks. A gastrostomy tube is ordered so that intermittent tube feedings can be administered. Question 25 of 31 Which intervention should the nurse initiate prior to beginning a feeding? Elevate the head of the bed 30 to 40 degrees. Check bowel sounds to determine if client is hungry. Deflate the gastrostomy balloon from 20 mL to 10 mL. Cleanse the gastrostomy insertion site with ½ strength hydrogen peroxide.
Elevate the head of the bed 30 to 40 degrees. The head of the bed should be elevated to prevent aspiration. KPotter, P., Perry, A., Stockert, P., Hall, A. (2019). Essentials for Nursing Practice. (9th edition). St. Louis, Missouri. Elsevier. Pg. 987. Check bowel sounds to determine if client is hungry. The presence of bowel sounds does not determine hunger. Deflate the gastrostomy balloon from 20 mL to 10 mL. The balloon should stay inflated to ensure that the feeding tube remains in place. Cleanse the gastrostomy insertion site with ½ strength hydrogen peroxide. Because the skin around the gastrostomy tube may become irritated from the enzymatic action of gastric juices that leak around the tube, the stoma should be cleansed daily, but with soap and water. This is not done prior to each feeding.
Client has difficulty communicating with the rehabilitation team and his son is very upset that his father can't communicate. The son tells the nurse that client has always been an eloquent speaker. The son has been helping his father by answering questions for him and trying to anticipate his needs. Question 23 of 31 What action should the nurse implement to address this situation? Encourage son to continue trying to anticipate his dad's needs. Inform the son that client's speech therapist will be able to help soon. Discuss how to use a communication board with both client and his son. Reassure the son that client's speech will become clearer as he gets better.
Encourage son to continue trying to anticipate his dad's needs. Although the son should be encouraged and praised for helping his father, the nurse should discourage this behavior. Client should attempt to do as much for himself as possible. Inform the son that client's speech therapist will be able to help soon. While this may be true, the nurse should address the situation. Discuss how to use a communication board with both client and his son. A communication board has pictures of common needs and phrases that help with communication. The nurse can easily teach this effective technique to both of them. Potter, P., Perry, A., Stockert, P., Hall, A. (2019). Essentials for Nursing Practice. (9th edition). St. Louis, Missouri. Elsevier. Pg. 196. Reassure the son that client's speech will become clearer as he gets better. Client's speech may become better, but it may not. This is false reassurance.
Section 10 Nursing Interventions Question 17 of 31 Client is experiencing homonymous hemianopsia as the result of his stroke. Which nursing intervention would the nurse implement to address this condition? Ensure that client sits in the chair four times a day. Place the objects client needs for activities of daily living on the right side of the table. Use a communication board when conversing with client. Reorient client to time, place and situation during nursing interventions.
Ensure that client sits in the chair four times a day. This intervention would address the client's immobility risks due to paralysis, not the homonymous hemianopsia. Place the objects client needs for activities of daily living on the right side of the table. Homonymous hemianopsia is loss of the visual field blindness in the same half of each visual field. This results in the client neglecting that side of the body, so it is beneficial to place objects on that side. Client had a right-hemisphere stroke so his left side is the weak side. Linton, A., Matteson, M. (2020). Medical-Surgical Nursing. (7th edition). St. Louis, Missouri. Elsevier. Pg. 405, 411, 417. Use a communication board when conversing with client. That intervention would address the client's verbal deficits due to aphasia. Reorient client to time, place and situation during nursing interventions. This intervention would address client's cognitive deficits.
Section 9 Health Promotion and Maintenance Question 15 of 31 Client's son asks the nurse, "Why did my dad have this stroke? Does this mean I might have a stroke when I get older?" The nurse discusses the difference between modifiable and nonmodifiable risk factors for a stroke. Which conditions are considered a modifiable risk factor for a stroke? (Select all that apply. One, some or all options may be correct.) Select all that apply High cholesterol levels. Diet. Lifestyle. History of atrial fibrillation. Advanced age.
High cholesterol levels. High cholesterol can lead to the development of plaque in the arteries. With interventions such as proper diet and medications, such as statins, this risk can be lowered. Linton, A., Matteson, M. (2020). Medical-Surgical Nursing. (7th edition). St. Louis, Missouri. Elsevier. Pg. 398. Diet. A diet high in fruits and vegetables, moderate in low fat dairy, and low in animal protein is recommended. The DASH (Dietary Approaches to Stop Hypertension) should be incorporated into education about risk management programs for strokes. Linton, A., Matteson, M. (2020). Medical-Surgical Nursing. (7th edition). St. Louis, Missouri. Elsevier. Pg. 398. Lifestyle. Regular exercise is recommended as part of a healthy lifestyle to decrease the risk of a stroke. Linton, A., Matteson, M. (2020). Medical-Surgical Nursing. (7th edition). St. Louis, Missouri. Elsevier. Pg. 398. History of atrial fibrillation. Heart disease, particularly atrial fibrillation, can predispose the client to clot formation on the wall of the heart or valve leaflets. This is a modifiable risk factor if treated with medication. Linton, A., Matteson, M. (2020). Medical-Surgical Nursing. (7th edition). St. Louis, Missouri. Elsevier. Pg. 398. Advanced age. People over 55 years old are a high-risk group for a stroke because the incidence of stroke more than doubles in each successive decade of life. However, modifiable risk factors can be changed; the client cannot do anything to change this risk factor, which makes it a nonmodifiable risk factor.
Question 13 of 31 Client spends 3 days in the ICU. Once stabilized, he is transferred to a 30-bed medical unit. Client 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 orders bedrest and sitting upright in a chair 4 times a day. Which nursing problem has the highest priority? Mobility. Inability to care for himself. Impaired communication. Swallowing problems.
Mobility. Although client has right-sided paralysis, that is not the highest priority. Inability to care for himself. Although client has facial drooping, that is not the highest priority. Impaired communication. Although client has difficulty communicating due to the aphasia, that is not the highest priority. Swallowing problems. According to Maslow's Hierarchy of Needs, physiological needs should be addressed first. Therefore, client's drooling indicates difficulty swallowing (dysphagia). This has the highest priority nursing issue because client is at risk for aspiration. Linton, A., Matteson, M. (2020). Medical-Surgical Nursing. (7th edition). St. Louis, Missouri. Elsevier. Pg. 404, 408.
Question 18 of 31 Client is experiencing pain in his left shoulder. The nurse is aware that up 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 activities. Which intervention should the nurse implement when addressing this condition? Move client by lifting with the affected shoulder. Teach client's son how to perform daily passive range of motion (ROM) exercises for his dad. Instruct client to limit attempts to move the affected arm. Instruct client to clasp the left hand with the right hand and raise both hands above the head.
Move client by lifting with the affected shoulder. The nurse should never lift or pull the client by the affected shoulder. Teach client's son how to perform daily passive range of motion (ROM) exercises for his dad. The client should perform active ROM exercises should be performed at least every 4 hours. Passive ROM does not promote independence for the client. Instruct client to limit attempts to move the affected arm. This will contribute to disuse syndrome. The nurse should teach that the affected arm should be elevated to prevent dependent edema in the hand. Instruct client to clasp the left hand with the right hand and raise both hands above the head. This exercise helps prevent "frozen shoulder" and will aid the nurse when moving or positioning the client. Potter, P., Perry, A., Stockert, P., Hall, A. (2019). Essentials for Nursing Practice. (9th edition). St. Louis, Missouri. Elsevier. Pg. 749.
The nurse remains with son at client's bedside. The HCP is called and pronounces client's death. The son tells the nurse that client wanted to be an organ donor. Question 29 of 31 What actions should the nurse implement? (Select all that apply. One, some or all options may be correct.) Select all that apply Obtain the necessary permits and notify the regional organ donor center. Explain that client can only be a tissue donor, not an organ donor. Explain that since client was on heparin recently he cannot be a donor. Remove all of client's tubes and wash his body. Call the local funeral home to come and receive the body.
Obtain the necessary permits and notify the regional organ donor center. This action is required. Potter, P., Perry, A., Stockert, P., Hall, A. (2019). Essentials for Nursing Practice. (9th edition). St. Louis, Missouri. Elsevier. Pg. 697, 699. Explain that client can only be a tissue donor, not an organ donor. The son needs the correct information. The client must be on a ventilator and declared "brain dead" prior to donating body organs such as the heart, lungs, liver, and pancreas (oxygen is needed for viability). Corneas, skin, bones, and joints can be donated from deceased donors who suffer cardiac death. These tissues can be recovered up to 24 hours after death. In some circumstances, kidneys can also be obtained from nonventilated deceased clients. Potter, P., Perry, A., Stockert, P., Hall, A. (2019). Essentials for Nursing Practice. (9th edition). St. Louis, Missouri. Elsevier. Pg. 697, 699. Explain that since client was on heparin recently he cannot be a donor. This is false information. Heparin does not affect the ability to donate organs or tissues. Remove all of client's tubes and wash his body. This is not one the first actions that the nurse should implement. Some facilities do not allow the nurse to remove the client's external tubes. Hospital policy/procedures should be followed. Call the local funeral home to come and receive the body. This action is not correct. The organ procurement team must first evaluate the body for donation criteria.
Section 12 Health Promotion and Maintenance Client is progressing physically and is transferred to the rehabilitation unit. He continues to have total left-sided paralysis, facial drooping, dysphagia, and visual field deficits. He still has an indwelling urinary catheter. He is scheduled for 3 hours of physical and occupational therapy daily. The rehabilitation team meets to discuss the plan of care and establish goals with appropriate interventions. Question 22 of 31 Which interventions should the nurse implement to prevent joint deformities? (Select all that apply. One, some or all options may be correct.) Select all that apply Place client in a prone position for 15 minutes at least 4 times a day. Position the fingers so that they are totally flexed in a slight pronation position. Place the elbow higher than the shoulder and the wrist higher than the elbow on the affected side. Apply splints to the arms and legs at night. When positioned on his side, client's upper thigh should be in the flexed position.
Place client in a prone position for 15 minutes at least 4 times a day. This helps to promote hyperextension of the hip joints, which helps prevent knee and hip flexion contractures. Cooper, K., Gosnell, K. (2019). Adult Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 664. Position the fingers so that they are totally flexed in a slight pronation position. The fingers should be barely flexed and placed in supination (palm faces upward), the normal anatomical position. Place the elbow higher than the shoulder and the wrist higher than the elbow on the affected side. The elbow should be higher than the shoulder and the wrist higher than the elbow to prevent edema and possible joint fibrosis that will occur and limit range of motion if client regains use of the arm. Cooper, K., Gosnell, K. (2019). Adult Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 664. Potter, P., Perry, A., Stockert, P., Hall, A. (2019). Essentials for Nursing Practice. (9th edition). St. Louis, Missouri. Elsevier. Pg. 750. Apply splints to the arms and legs at night. Because flexor muscles are stronger than extensor muscles, posterior splints should be applied at night to prevent flexion and maintain correct positioning during sleep. Cooper, K., Gosnell, K. (2019). Adult Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 664. When positioned on his side, client's upper thigh should be in the flexed position. To promote venous return and prevent edema, the upper thigh should not be flexed.
Question 24 of 31 Which rehabilitation team member is responsible for evaluating client's dysphagia? The rehabilitation HCP. The speech therapist. The case manager. The occupational therapist.
The rehabilitation HCP. The HCP does not evaluate dysphagia. The speech therapist. The speech therapist evaluates the client's gag reflex and ability to swallow, then makes recommendations regarding feeding techniques and diet. Potter, P., Perry, A., Stockert, P., Hall, A. (2019). Essentials for Nursing Practice. (9th edition). St. Louis, Missouri. Elsevier. Pg. 984, 987. The case manager. The case manager is usually a nurse who coordinates the client's care with the multidisciplinary team members. The occupational therapist. The occupational therapist helps clients achieve independence in activities of daily living.
Section 8 Because client is left-handed and is having difficulty performing activities of daily living with his left arm, the nurse knows that another important nursing problem for client is his inability to care for himself. The PN nurse discusses this with the RN charge nurse for inclusion in the problem list so appropriate goals and interventions can be added by the RN. Question 14 of 31 Which nursing intervention should be implemented to address client's inability to care for himself? Use narrow grip utensils to accommodate a weak grasp. Use plate guards when client is eating. Only provide meals when the son is able to assist. Ask the HCP to reduce the order for sitting up in a chair from 4 times a day to twice a day to prevent potential injury.
Use narrow grip utensils to accommodate a weak grasp. Wide-grip utensils should be used to accommodate a weak grasp. Use plate guards when client is eating. Plate guards prevent food from being pushed off the plate. Using plate guards and other assistive devices will encourage independence in a client with issues relating to the inability to care for themselves. Linton, A., Matteson, M. (2020). Medical-Surgical Nursing. (7th edition). St. Louis, Missouri. Elsevier. Pg. 413. Only provide meals when the son is able to assist. This will not encourage independence for client. Ask the HCP to reduce the order for sitting up in a chair from 4 times a day to twice a day to prevent potential injury. This intervention will not promote strength building for the client.
Section 15 Psychosocial Integrity The son requests clergy to pray with him. Question 30 of 31 Which action would be most important for the nurse to take in this situation? Notify the case manager. Have clergy come to pray. Tell the son that this is against hospital policy. Explain to the son that this is not a good idea because it will only cause him more grief.
Which action would be most important for the nurse to take in this situation? Notify the case manager. The case manager is not needed at this time. Have clergy come to pray. The nurse should support the client's religious beliefs. Kwong, M., Harding, D., Roberts, C., Reinisch, D., & Hagler, J. (2020). Lewis's Medical-Surgical Nursing. (11th edition). St. Louis, Missouri. Elsevier. Pg. 129, 131. Tell the son that this is against hospital policy. This is not a true statement and does not provide respect for the son's request. Explain to the son that this is not a good idea because it will only cause him more grief. This action does not support the son's request.