HESI Case Studies – Brain Attack (Stroke) – Flashcards
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Which additional clinical manifestation(s) should the nurse expect to find if Nancy's symptoms have been caused by a brain attack (stroke)? (select all that apply)
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A carotid bruit. Elevated blood pressure. Difficulty swallowing.
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Which assessment finding warrants immediate intervention by the nurse?
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Nancy only responds to painful stimuli.
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Which clinical manifestation further supports this assessment?
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Global aphasia.
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Which nursing intervention should the nurse implement when preparing Nancy and her daughter for this procedure?
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Explain to the daughter that her mother will have to remain still throughout the CT scan.
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Which data warrants immediate intervention by the nurse concerning this diagnostic test?
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Right hip replacement.
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Which response is best by the nurse?
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"Your mother has had a stroke, and the blood supply to the brain has been compromised."
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How should the nurse respond?
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"I know this is scary for you. Would you like to sit and talk?"
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Nancy weighs 145 pounds. How many mg of enoxaparin (Lovenox) will the nurse administer? (round to the nearest whole number)
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66.
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With a diagnosis of a brain attack (stroke), which priority intervention should the nurse include in Nancy's plan of care?
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Keep the head of bed elevated.
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Which finding would require immediate intervention by the nurse?
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Nancy's cardiac output is less than 4L/min.
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Which nursing intervention(s) would be priority at this time? (select all that apply)
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Monitor level of consciousness. Strick intake and output. Monitor capillary refill every 2-4 hours. Contact physician.
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How should the nurse respond?
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"She is not a candidate because of therapeutic time constraints related to this medication."
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Which nursing diagnosis has the highest priority?
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Impaired swallowing.
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Which intervention would the nurse implement to address this nursing diagnosis?
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Utilize plate guards when Nancy is eating.
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Which condition is considered a non-modifiable risk factor for a brain attack?
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Advanced age.
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Which statement is warranted in this situation?
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"I should let you know that smoking is a strong risk factor for a brain attack."
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Which nursing intervention would the nurse implement to address this condition?
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Place the objects Nancy needs for activities of daily living on the left side of the table.
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Which intervention should the nurse implement when addressing this condition?
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Instruct Nancy to clasp the right hand with the left hand and raise both hands above the head.
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How should the nurse respond?
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"That procedure is only done with small strokes, not like the one your mom had."
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Which nursing care task should the nurse delegate to the UAP?
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Give Nancy a bed bath and change the bed linens.
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Which written documentation should the nurse put in the client's record?
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PT reported that client became dizzy and was lowered back to the bed with the assistance of a gain belt.
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Which intervention should the nurse implement to prevent joint deformities?
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Place Nancy in a prone position for 15 minutes at least 4 times a day.
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What action should the nurse implement to address this situation?
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Discuss how to use a communication board with both Nancy and her daughter.
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Which rehabilitation team member is responsible for evaluating Nancy's dysphagia.
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The speech therapist.
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Which intervention should the nurse implement while Nancy is receiving tube feedings?
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Cleanse the gastrostomy insertion site with soap and water daily.
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At what rate would the nurse set the infusion pump?
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60mL/hr.
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Which intervention should the nurse implement?
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Continue to stay at Nancy's bedside and hold Gail's hand.
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How should the nurse respond.
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"I am sorry, but I am unable to give you any information."
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Which action should the nurse implement?
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Explain that Nancy can only be a tissue donor, not an organ donor.
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Which action should the nurse implement?
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Notify the chaplain services immediately so the priest can come to the bedside.
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How should the nurse respond?
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"You seem really confused about what to do. Would you like to take about it?"
