HESI Case Studies- Stroke
How should the nurse respond?
I am sorry, but I am unable to give you any information.
How should the nurse respond?
I know this is scary for you. Would you like to sit and talk?
Which statement is warranted in this situation?
I should let you know that smoking is a strong risk factor for a stroke.
Which nursing diagnosis has the highest priority?
Impaired swallowing
Which written documentation should the nurse put in the client's record?
PT reported that client stated he felt dizzy and was lowered to the bed assisted by the PT using a gait belt.
How should the nurse respond?
You seem really confused about what to do. Would you like to talk about it?
Which explanation by the nurse is the most therapeutic response?
Your father has had a stroke, and the blood supply to the brain has been compromised.
With a diagnosis of stroke, which priority intervention should the nurse include in Mr. Jones' plan of care? (select all that apply)
-Monitor PTT daily -Assess neurological status every hour -Keep the head of the bed elevated -Monitor blood glucose levels daily
Which additional clinical manifestations should the nurse expect to find if Mr. Jones' symptoms have been caused by a stroke? (select all that apply)
-a carotid bruit -elevated blood pressure -hyporeflexic deep tendon reflexes
Which conditions are considered a modifiable risk factor for a stroke? (select all that apply)
-high cholesterol levels -diet -lifestyle -history of atrial fibrillation
What actions should the nurse implement? (select all that apply)
-obtain the necessary permits and notify the regional organ donor center -Explain that Mr. Jones can only be a tissue donor, not an organ donor
At what rate would the nurse set the infusion pump?
75
How many mg of enoxaparin will the nurse administer in each dose?
77
What action should the nurse implement to address this situation?
Discuss how to use a communication board with both Mr. Jones and Barry.
Which intervention should the nurse implement when addressing this condition?
Instruct Mr. Jones to clasp the left hand with the right hand and raise both hands above the head.
Which data warrants immediate intervention by the nurse concerting this diagnostic test?
Left hip replacement
Which nursing intervention would the nurse implement to address this condition?
Place the objects Mr. Jones needs for activities of daily living on the right side of the table.
How should the nurse respond?
That procedure is only done with small strokes, not like the one your dad had.
Which rehabilitation team member is responsible for evaluating Mr. Jones' dysphagia?
The speech therapist
Which nursing interventions would be priority at this time? (select all that apply)
-Monitor level of consciousness -Monitor intake and output hourly -Monitor capillary refill every 2 to 4 hours -Monitor pulse oximetry
Which assessment findings warrant immediate intervention by the nurse? (select all that apply)
-Mr. Jones' Glasgow Coma Scale (GCS) score changes from 12 to 9 -Mr. Jones has a positive Babinski's reflex bilaterally -Mr. Jones is unable to verbalize responses to the nurse's questions
Which finding would require immediate intervention by the nurse? (select all that apply)
-Mr. Jones' pulse oximeter reading has been 90% for the past 2 hours -Mr. Jones' serum potassium level is 3.0 mEq/L -Mr. Jones' serum glucose is 150
Which interventions should the nurse implement to prevent joint deformities? (select all that apply)
-place Mr. Jones in a prone position for 15 minutes at least 4 times a day -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
Which nursing care task should the nurse delegate to the UAP? (select all that apply)
-take Mr. Jones' vital signs -give Mr. Jones a bed bath and change the bed linens -measure Mr. Jones' intake and output each shift (I&O)
What clinical manifestations further support this assessment? (select all that apply)
-visual field deficit on the left side -spatial-perceptual deficits -paresthesia on the left side -increased distractibility
Which intervention should the nurse implement first?
Continue to stay at Mr. Jones' bedside and hold Barry's hand.
Which intervention should the nurse perform prior to beginning a feeding?
Elevate the head of the bed 30 to 40 degrees.
Which intervention should the nurse implement when preparing Mr. Jones and his son for this procedure?
Explain that the procedure requires the client to lie completely still.
Which action would be most important for the nurse to take in this situation?
Have a clergy come to pray.
How should the nurse respond to Barry?
He is not a candidate because of therapeutic time constraints related to this medication.
Which nursing intervention should the nurse implement to address Mr. Jones' self-care deficit?
Use plate guards when Mr. Jones is eating.
