NU371 HESI Case Study: Stroke
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.
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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.
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Which action would be most important for the nurse to take in this situation? a) Notify the case manager. b) Have clergy come to pray. c) Tell the son that this is against hospital policy. d) Explain to the son that this is not a good idea because it will only cause him more grief.
b) Have clergy come to pray. - The nurse should support the client's religious beliefs.
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."
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Over the next 24 hour, client's SaO2, potassium level, and telemetry readings are within normal limits for his age, but his cardiac output decreases. The HCP needs to be notified regarding decreased cardiac output to decide whether to initiate IV fluid if hypovolemia is an issue and to determine other medical interventions.
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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.
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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?"
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The telephone at client's bedside starts ringing. The nurse answers the phone. The caller is client's pastor, asking how he is doing.
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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.
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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.
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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.
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The neurologist diagnoses an ischemic right-sided stroke. The neurologist determines that Mr. Jones is not a candidate for tissue plasminogen activator (tPA). Enoxaparin 1 mg/kg subcutaneously every 12 hours is prescribed.Mr. Jones weighs 170 pounds. How many mg of enoxaparin will the nurse administer in each dose? (Enter the numerical value only. If rounding is required, round to the whole number).
170 lbs/2.2 kg = 77 kg 1 mg/kg x 77 kg= 77 mg
The 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.)
8 ounces x 30 mL/ounce= 240 mL 360 mL + 240 mL= 600 mL 600 mL/8 hours= 75 mL/hr
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.
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.
Therapeutic Communication
Client is transferred to the Neurological Intensive Care Unit (ICU) after the MRI is completed. He has a 20 gauge saline lock in his right forearm and an 18 French indwelling urinary catheter. His son is sitting by his father's bed. The nurse asks the son if there is anyone who can be called so he won't be alone. He informs the nurse that his mother died 2 years ago and his closest relative is a cousin who lives out of state. The son states, "I don't understand what a stroke is. The HCP told me that my father is in serious condition and they are going to run several tests. I just don't know what is going on. What happened to my father?"
Meet the Client
Client, a 72-year-old male widower, lives with his son. Client tells his son that he has a headache and that he is not feeling well. Son notices some left-sided weakness in his father and takes client to the Emergency Department (ED).
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.
Psychosocial Integrity
The son requests clergy to pray with him.
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.
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? a) "I should also let you know that smoking is a strong risk factor for a stroke." b) "Ok, I will be sure your father is well taken care of in your absence." c) "Make sure you smoke in the smoking area only. The hospital has strict rules." d) "Does smoking help you cope with stressful situations?"
a) "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.
Following the ED healthcare provider's (HCP) assessment, the nurse continues to do focused assessments on the client every 15 minutes. Client's son sits at the bedside while the nurse assesses his father. Which assessment findings warrant immediate intervention by the nurse? (Select all that apply. One, some or all options may be correct.) a) Client's Glasgow Coma Scale (GCS) score changes from 12 to 9. b) Client's motor strength is unequal. c) Client responds to painful stimuli. d) Client has a positive Babinski's reflex bilaterally. e) Client is unable to verbalize responses to the nurse's questions.
a) Client's Glasgow Coma Scale (GCS) score changes from 12 to 9. d) Client has a positive Babinski's reflex bilaterally. e) Client is unable to verbalize responses to the nurse's questions.
Which intervention should the nurse initiate prior to beginning a feeding? a) Elevate the head of the bed 30 to 40 degrees. b) Check bowel sounds to determine if client is hungry. c) Deflate the gastrostomy balloon from 20 mL to 10 mL. d) Cleanse the gastrostomy insertion site with ½ strength hydrogen peroxide.
a) Elevate the head of the bed 30 to 40 degrees. - The head of the bed should be elevated to prevent aspiration.
Which conditions are considered a modifiable risk factor for a stroke? (Select all that apply. One, some or all options may be correct.) a) High cholesterol levels. b) Diet c) Lifestyle. d) History of atrial fibrillation. e) Advanced age.
a) High cholesterol levels. b) Diet c) Lifestyle. d) History of atrial fibrillation. - 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. 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. Regular exercise is recommended as part of a healthy lifestyle to decrease the risk of a stroke. 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.
The ED RN completes the full admission assessment and the assigned PN is present. Client is alert but struggles to answer questions. When he attempts to talk, he slurs his speech and appears very frightened. Which additional clinical manifestations should the nurse expect to find if client's symptoms have been caused by a stroke? (Select all that apply. One, some, or all options may be correct.) a) Hyperglycemia. b) Elevated blood pressure. c) Arrhythmias. d) Amblyopia e) Difference in temperature of upper and lower extremities.
a) Hyperglycemia. b) Elevated blood pressure. c) Arrhythmias. - Hyperglycemia (elevated blood sugar) may represent the body's stress response during a stroke and has been shown to contribute to brain damage and more severe outcomes.When a client has a stroke, the blood pressure will often respond by increasing. Increased blood pressure is also a sign of increased intracranial pressure and could signal worsening of brain tissue damage.Cardiac rhythms may become abnormal after a stroke. Continuous cardiac monitoring is recommended to monitor ischemic heart changes and abnormal rhythms like atrial fibrillation.
With a diagnosis of a stroke, which priority interventions should the nurse implement from the client's plan of care? (Select all that apply. One, some or all options may be correct.) a) Monitor PTT daily. b) Assess neurological status every hour. c) Evaluate platelet levels daily. d) Keep the head of the bed elevated. e) Monitor blood glucose levels daily.
a) Monitor PTT daily. b) Assess neurological status every hour. d) Keep the head of the bed elevated. e) Monitor blood glucose levels daily. - The nurse should monitor the PTT level during heparin therapy. INR is monitored with warfarin therapy. The neurological status must be monitored every hours or more frequently if status changes indicate or per ICU protocol. Maintaining a patent airway is essential to support oxygenation and cerebral perfusion. Elevating the head of the bed 30 degrees aids in preventing the tongue from falling backward and obstructing the airway. Hyperglycemia has been associated with poor neurologic outcomes in acute stroke clients and glucose levels above 140 mg/dL (7.77 mmol/L) should be treated.
Which nursing interventions would be priority at this time? (Select all that apply. One, some or all options may be correct.) a) Monitor level of consciousness (LOC). b) Monitor vital signs every shift. c) Monitor intake and output every hour. d) Monitor capillary refill every 2 to 4 hours. e) Monitor pulse oximetry.
a) Monitor level of consciousness (LOC). c) Monitor intake and output every hour. d) Monitor capillary refill every 2 to 4 hours. e) Monitor pulse oximetry. - With a decreased cardiac output, cerebral perfusion will be affected. This can be reflected in a further decreased level of consciousness. The kidneys use 25% of cardiac output, so when cardiac output is decreased, the kidneys may start failing. Close monitoring is essential. Decreased cardiac output would affect tissue perfusion, reflected in a capillary refill of greater than 3 seconds. Pulse oximetry will give an indication of any changes subtle or sudden changes in oxygen saturation.
What actions should the nurse implement? (Select all that apply. One, some or all options may be correct.) a) Obtain the necessary permits and notify the regional organ donor center. b) Explain that client can only be a tissue donor, not an organ donor. c) Explain that since client was on heparin recently he cannot be a donor. d) Remove all of client's tubes and wash his body. e) Call the local funeral home to come and receive the body.
a) Obtain the necessary permits and notify the regional organ donor center. b) 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.
The neurologist writes a diagnosis of "suspected stroke" and prescribes a computed tomography (CT) scan without contrast STAT. Which intervention should the nurse implement when preparing client and his son for this procedure? a) Determine if the client has any allergies to iodine or shellfish. b) Explain that the procedure requires the client to lie completely still. c) Offer client an anxiolytic prior to the procedure. d) Ensure that client does not have on any material that is metal, this includes metal prosthesis.
b) Explain that the procedure requires the client to lie completely still. - Because head motion will distort the images, client will have to remain still throughout the procedure. Since client has a decreased level of consciousness (LOC), he may require head support to accomplish this.
Which interventions should the nurse implement to prevent joint deformities? (Select all that apply. One, some or all options may be correct.) a) Place client in a prone position for 15 minutes at least 4 times a day. b) Position the fingers so that they are totally flexed in a slight pronation position. c) Place the elbow higher than the shoulder and the wrist higher than the elbow on the affected side. d) Apply splints to the arms and legs at night. e) When positioned on his side, client's upper thigh should be in the flexed position.
a) Place client in a prone position for 15 minutes at least 4 times a day. c) Place the elbow higher than the shoulder and the wrist higher than the elbow on the affected side. d) Apply splints to the arms and legs at night. - This helps to promote hyperextension of the hip joints, which helps prevent knee and hip flexion contractures. 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. Because flexor muscles are stronger than extensor muscles, posterior splints should be applied at night to prevent flexion and maintain correct positioning during sleep.
Due to his deteriorating condition, the neurologist is consulted to immediately see client. The nurse suspects that client has probably suffered a right-sided stroke. Which clinical manifestations further support this assessment? (Select all that apply. One, some or all options may be correct.) a) Visual field deficit on the left side. b) Spatial-perceptual deficits. c) Full or partial paralysis of the left side: hemiplegia. d) Increased distractibility and attention span. e) Global aphasia.
a) Visual field deficit on the left side. b) Spatial-perceptual deficits. c) Full or partial paralysis of the left side: hemiplegia. d) Increased distractibility and attention span.
As the nurse assesses client, his son asks, "Why isn't my dad a candidate for thrombolytic therapy?" How should the nurse respond? a) "I think that is something you should discuss with your father's HCP." b) "He is not a candidate because of therapeutic time constraints related to this medication." c) "Thrombolytic therapy is usually not administered to anyone older than 65 years." d) "Since your father was alert on admission, he is not a candidate to receive this medication."
b) "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.
The son is visibly upset and states, "Dad has been fine all week. We even went out to dinner. I love him so much and I am scared." How should the nurse respond? a) "I wouldn't worry if I were you, I am sure things be ok." b) "I know this is scary for you. Would you like to sit and talk?" c) "I can call your pastor to come and sit with you so you won't be alone." d) "Hang in there. Can you call a friend to come and sit with you until you feel better?"
b) "I know this is scary for you. Would you like to sit and talk?" - This therapeutic response provides acknowledgment of the son's concerns, and the nurse offers to take time to discuss the situation.
How should the nurse respond? a) "I think that lady misunderstood her mother's surgical procedure." b) "That procedure is only done with small strokes, not like the one your dad had." c) "Yes, it is a carotid endarterectomy, and your father may be able to have one." d) "That is a question you should ask your dad's HCP."
b) "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.
Which explanation by the nurse is the most therapeutic response? a) "I am sorry, that information is protected by HIPAA." b) "Your father has had a stroke, and the blood supply to the brain has been compromised." c) "Why didn't you ask the HCP any questions?" d) "You can access information from the internet by using your cell phone."
b) "Your father has had a stroke, and the blood supply to the brain has been compromised." - The nurse has the knowledge and the responsibility, to explain client's condition to the son.
The nurse continues to closely monitor client's condition. Which findings would require immediate intervention by the nurse? (Select all that apply. One, some or all options may be correct.) a) Client's cardiac output is 5 L/min. b) Client's pulse oximeter reading has dropped to 90%. c) Client's serum potassium level is 3.0 mEq/L (mmol/L). d) Client's telemetry shows normal sinus rhythm with occasional premature ventricular contractions (PVCs). e) Client's serum glucose is 150 (8.32 mmol/L).
b) Client's pulse oximeter reading has dropped to 90%. c) Client's serum potassium level is 3.0 mEq/L (mmol/L). e) Client's serum glucose is 150 (8.32 mmol/L). - A pulse oximeter reading of 90% indicates inadequate oxygenation to the peripheral tissues. The normal serum potassium level is 3.5 to 5.5 mEq/L (mmol/L). Hyperglycemia has been associated with poor neurologic outcomes in acute stroke clients and glucose levels above 140 mg/dL (7.77 mmol/L) should be treated.
Which intervention should the nurse implement first? a) Call the rapid response team (RRT). b) Continue to stay at client's bedside and offer the son support. c) Provide two rescue breaths and call a "CODE." d) Ask son to leave the room while the nurse assess the apical pulse.
b) 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.
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? a) Client experienced orthostatic hypotension when getting out of bed. b) PT reported that client stated he felt dizzy and was lowered to the bed assisted by the PT using a gait belt. c) PT notified the primary nurse that the client could not ambulate at this time because of dizziness. d) Client had difficulty ambulating from the bed to the chair when accompanied by the PT, variance report completed.
b) 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.
Client is experiencing homonymous hemianopsia as the result of his stroke. Which nursing intervention would the nurse implement to address this condition? a) Ensure that client sits in the chair four times a day. b) Place the objects client needs for activities of daily living on the right side of the table. c) Use a communication board when conversing with client. d) Reorient client to time, place and situation during nursing interventions.
b) 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.
Which rehabilitation team member is responsible for evaluating client's dysphagia? a) The rehabilitation HCP. b) The speech therapist. c) The case manager. d) The occupational therapist.
b) The speech therapist. - The speech therapist evaluates the client's gag reflex and ability to swallow, then makes recommendations regarding feeding techniques and diet.
Which nursing intervention should be implemented to address client's inability to care for himself? a) Use narrow grip utensils to accommodate a weak grasp. b) Use plate guards when client is eating. c) Only provide meals when the son is able to assist. d) 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.
b) 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.
How should the nurse respond? a) "I am so sorry, but he just passed away." b) "I will have his call you at a later time." c) "I am sorry, but I am unable to give you any information." d) "Let me have your number so I can call you back in a few minutes."
c) "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."
How should the nurse respond? a) "You should do what your father wanted." b) "I will contact your pastor and you can ask him what you should do." c) "You seem really confused about what to do. Would you like to talk about it?" d) "Isn't cremation cheaper than a funeral?"
c) "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.
What action should the nurse implement to address this situation? a) Encourage son to continue trying to anticipate his dad's needs. b) Inform the son that client's speech therapist will be able to help soon. c) Discuss how to use a communication board with both client and his son. d) Reassure the son that client's speech will become clearer as he gets better.
c) 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.
The neurologist also prescribes a magnetic resonance imaging (MRI) of the head STAT. Which data warrants immediate intervention by the nurse concerning this diagnostic test? a) Elevated heart rate. b) Allergy to iodine. c) Left hip replacement. d) History of hypertension.
c) Left hip replacement. - The magnetic field generated by the MRI is so strong that metal-containing items are strongly attracted to the magnet. Because the hip joint is made of metal, a lead shield must be used during the procedure.
Which nursing care task should the nurse delegate to the UAP? (Select all that apply. One, some or all options may be correct.) a) Assist client with his breakfast. b) Assist client in getting in the chair. c) Take client's vital signs. d) Give client a bed bath and change the bed linens. e) Measure client's intake and output each shift (I&O).
c) Take client's vital signs. d) Give client a bed bath and change the bed linens. e) Measure client's intake and output each shift (I&O).
Which intervention should the nurse implement when addressing this condition? a) Move client by lifting with the affected shoulder. b) Teach client's son how to perform daily passive range of motion (ROM) exercises for his dad. c) Instruct client to limit attempts to move the affected arm. d) Instruct client to clasp the left hand with the right hand and raise both hands above the head.
d) 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.
Which nursing problem has the highest priority? a) Mobility b) Inability to care for himself. c) Impaired communication. d) Swallowing problems.
d) 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.