vsim Russell
The nurse is caring for a patient who has experienced a sudden change in level of consciousness and has difficulty speaking. What is the priority action of the nurse?
Assess the patient
Which observation supports the possibility that a patient who has experienced a stroke has aspirated?
coughing, hoarseness, regurgitation into the mouth
When taking a patient's health history, which of the following does the nurse identify as risk factors for having a stroke? (select all that apply) a. diabetes mellitus b. recent weight loss c. smoking d. hypertension e. asthma
d. hypertension c. smoking a .diabetes mellitus
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?
-decreasing level of consciousness -unequal pupils
Mr Russell experienced dysphagia and mild left-sided weakness following his stroke. For which additional symptoms of stroke should the nurse assess?
-urinary incontinence -sensory deficits -communication difficulties
The nurse is evaluating a patient's neurological status. What should the nurse include when assessing a patient's level of awareness?
Assess: time, place, person
A patient is experiencing dysphagia following a stroke. How should the nurse position the patient when administering medications?
High Fowler's
A patient with dysphagia following a stroke express concern about having difficulty eating and drinking. What is the appropriate reply by the nurse?
Muscle weakness frequently occurs after a stroke; we need to make sure food is not going into your lungs.
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 result does the nurse anticipate reviewing prior to administering this medication?
PT/INR
The nurse is calling in a report to the provider using SBAR format. Which statement by the nurse would be the "S" when using this reporting technique?
The patient began coughing when eating breakfast this morning
The nurse is caring for four medical-surgical patients. Which patient should be assess using the Glasgow Coma Scale?
a 47yo patient who has suffered a brain injury and lost consciousness in a motor vehicle accident.
The nurse is assessing a patient using the Glasgow Coma Scale. Which of the following are components of that scale?
-eye opening -motor response -verbal response
Mr Russell is being discharged from the hospital following a mild stroke. What instruction would the nurse include in discharge education?
it is important that you begin a smoking cessation program
The nurse has an order to complete neurochecks every four hours. Which assessments would the nurse include in the neurological examination?
memory, level of consciousness, sensory perception, cranial nerves
The nurse is assessing Mr Russell's pupillary response. List the steps of the procedure in the order they should be performed.
-darken the room -ask the patient to look straight ahead -bring the penlight in from the side of the patient's face and briefly shine light on pupil -observe pupil's reaction -repeat procedure with the same eye, but this time, observe the other eye -repeat the procedure with the other eye
Mr Russell has been placed on fall precautions. What actions should the nurse take to keep the patient safe?
-maintain bed in low position -place the call bell within reach -instruct patient to call for assistance when out of bed -provide non-skid socks for ambulation
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?
-providing a 30 minute rest period prior to mealtimes -educating the patient about the importance of alternating liquids and solids -positioning patient upright in chair if not contraindicated
The nurse is caring for a patient who is suspected of having a stroke. What should be the nurse's first action to ensure patient safety when it appears the patient is having difficulty swallowing prescribed oral medication?
Hold this dose of medication and make the patient NPO