Post-Quiz Vernon Russel

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

- Eye opening - Motor response - Verbal response

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.

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 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.)

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

A patient has been admitted with a diagnosis of stroke, and the nurse has received orders to hold warfarin until labs 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 the 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.

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.)

- Communication difficulties - Sensory deficits - Urinary incontinence

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.)

- Decreasing level of consciousness - Unequal pupils

Mr. Russell has been placed on fall precautions. What actions should the nurse take to keep the patient safe? (Select all that apply.)

- Maintain bed in low position at all times. - Instruct patient to call for assistance when out of bed. - Place the call bell within reach. - Provide non-skid socks for ambulation.