VSIM Russell

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 should first darken the room and then ask the patient to look straight ahead. Next, the nurse should bring the penlight in from the side of the patient's face and briefly shine light on pupil, observing the patient's reaction. The nurse should then repeat the procedure on the same eye while observing the other eye. Finally, the nurse should repeat the procedure with the other eye.

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. If a patient has a sudden change in level of consciousness and has difficulty speaking, the priority action of the nurse is to assess the patient. The nurse would not wait 15 minutes to see if the problem resolved because the patient could experience permanent neurological damage. The nurse would notify the charge nurse and the provider after assessing the patient. The nurse would document the findings last.

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, Urinary incontinence, Sensory deficits In addition to dysphagia and muscle weakness, additional signs and symptoms of a stroke include communication difficulties, sensory deficits, and urinary incontinence. Hearing loss and decreased peristalsis are not indicative of a stroke.

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 Decreasing level of consciousness and changes in pupillary response may indicate that Mr. Russell is experiencing neurologic compromise. Mr. Russell was already experiencing left-sided weakness and difficulty swallowing following the stroke. Due to Mr. Russell's left-sided weakness, an unsteady gait would be expected.

A patient is experiencing dysphagia following a stroke. How should the nurse position the patient when administering medications?

High Fowler's The nurse should position the patient at 90 degrees (high Fowler's) or should sit the patient upright in a chair. The nurse should not position the patient supine (on back), semi-Fowler's (45 degrees), or left lateral (on the side) during medication administration, because these positions can impede swallowing and the passage of food/liquids into the stomach.

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. SBAR stands for situation, background, assessment, and recommendation. The situation (or the "S") statement is: The patient began coughing when eating breakfast this morning. The background statement is: The patient was admitted with stroke and mild left hemiplegia. The assessment statement is: The patient's lungs are clear to auscultation. The recommendation statement is: I recommend the patient be sent for a swallow study.

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

Coughing, Regurgitation into the mouth, Hoarseness When a stroke patient begins coughing, demonstrates hoarseness, or regurgitates after swallowing, the nurse should evaluate the possibility of aspiration. Vomiting and nausea are not associated with aspiration.

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 Eye opening, motor response, and verbal response are all components of the Glasgow Coma Scale. Respirations and brainstem reflexes are components of the Full Outline of UnResponsiveness (FOUR) Coma Scale.

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. Smoking is a risk factor for stroke. It is therefore important that the patient begin a smoking cessation program as soon as possible. Daily weights, low-protein diet, and taking medication only when symptoms are present would not be included in discharge education following a stroke.

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 lab result that the nurse should review prior to the administration of warfarin is PT/INR. The other labs are unrelated to the administration of warfarin.

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 Providing meals when the patient is rested and positioned properly will decrease the possible risk of choking and/or aspiration. Encouraging the patient to alternate the ingestion of liquids and solids will also help minimize the potential risks. While mouth care and appropriate positioning of the patient's food contribute to the patient's eating experience, they are not directly associated with minimizing the risks of choking and aspiration.

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.)

Smoking, Hypertension, Diabetes Mellitus Risk factors for stroke include hypertension, smoking, and diabetes. Obesity, not weight loss, is a risk factor for stroke. Asthma is not a risk factor for stroke.

The nurse is caring for four medical-surgical patients. Which patient should be assessed using the Glasgow Coma Scale?

A 47-year-old patient who suffered a brain injury and lost consciousness in a motor vehicle accident. The correct answer is a 47-year-old patient who suffered a brain injury and lost consciousness in a motor vehicle accident. The Glasgow Coma Scale measures Eye Opening, Verbal Response, and Motor Response and is typically used with patients who have suffered a brain injury as a result of trauma. The 32-year-old patient who is paraplegic was hospitalized for pneumonia, not a brain injury. The patient with cancer who has anxiety and depression nor the older adult patient with dementia did not experience a brain injury.

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. Difficulty swallowing may lead to aspiration. The nurse's first action should be to hold the medication dose and make the patient nothing by mouth (NPO). The nurse should then notify the provider, who will probably order a swallow study; this, however, is not the first action because patient safety is the priority. Educating the patient is an appropriate intervention but does not address the immediate issue of patient safety.

The nurse has an order to complete neurochecks every four hours. Which assessments would the nurse include in the neurological examination? (Select all that apply.)

Level of consciousness, Memory, Sensory perception, Cranial nerves Components of a neurological examination include memory, level of consciousness, sensory perception, cranial nerves, patterns of speech, and bilateral hand grips. Range of motion would be appropriate for a musculoskeletal assessment.

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., Place the call bell within reach., Instruct patient to call for assistance when out of bed., Provide non-skid socks for ambulation. A patient who is placed on fall precautions should have the bed maintained in the lowest position at all times, and the nurse should instruct the patient to call for assistance when out of bed. In addition, the nurse should place the call bell within reach and make sure that the patient has non-skid socks. Keeping all four side rails elevated is considered a restraint and may actually increase the patient's risk of falls.

A patient with dysphagia following a stroke expresses 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 that food is not going into your lungs. The appropriate reply by the nurse would be to explain that muscle weakness frequently occurs after a stroke. Making sure the GI tract is functioning would be an appropriate action to take after surgery. Telling the patient to ask the provider is inappropriate because the nurse is able to answer this question. Although the patient may seem worried, the question is specifically about patient teaching rather than therapeutic communication. The appropriate reply by the nurse would be to answer the patient's question.