HESI RN Case Studies-Brain Attack (Stroke) – Flashcards
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Which additional clinical manifestation(s) should the RN expect...
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-A cardiac bruit -Elevated blood pressure -Drooling
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Which assessment finding warrants immediate intervention by the RN? ...
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-Mrs. Jackson only responds to painful stimuli -Mrs. has a positive Babinski's reflex bilaterlly -Mrs.'s pupils are reacting unequally, and she is experiencing sensitivity to light
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Which clinical manifestation further supports this assessment?
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Global aphasia
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Which intervention should the RN implement when preparing Mrs. and her daughter...
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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...
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right hip replacement
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Which is the best response by the rn?
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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 rn respond?
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"I know this is scary for you. Would you like to sit and talk?"
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Mrs. weighs 145 Ibs. How many mg of enoxaparin will the nurse administer in each dose?
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66
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With a diagnosis of a brain attack (stroke), which priority intervention...
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Keep the head of the bed elevated
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Which finding would require immediate intervention by the rn?
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Mrs.'s cardiac output is less than 4 L/min
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Which nursing interventions would be priority at this time?
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-Monitor level of consciousness -Strictly monitor intake and output -Monitor capillary refill every 2-4 hrs -Contact physician
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How should the rn respond to Gail?
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"She is not a candidate because of the therapeutic time constraints related to this medication"
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Which nursing diagnosis has the highest priority?
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Drooling
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Which nursing intervention would the rn implement to address...
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Use plate guards when Mrs. Jackson is eating
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Which condition is considered a modifiable risk factor for a brain attack?
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-High cholesterol levels -Obesity -Hypertension -History of atrial fibrillation
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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 rn implement to address this condition?
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Place the objects Mrs. needs for activities of daily living on the left side of the table
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Which intervention should the rn implement when addressing this condition?
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Instruct Mrs. to clasp the right hand with the left hand and raise both hands above the head
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How should the rn respond?
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"That procedure is only done with small strokes, not like...
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Which nursing care task should the rn delegate to the UAP?
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Give Mrs. a bed bath and change the bed linens
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Which written documentation should the rn 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 gait belt
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Which intervention should the rn implement to prevent joint deformities?
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Place Mrs. in a prone position for 15 minutes at least 4 times a day
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What action should the rn implement to address this situation?
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Discuss how to use a communication board with both Mrs. and her daughter
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Which rehabilitation team member is responsible for evaluating Mrs.'s dysphagia?
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The speech therapist
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Which intervention should the rn implement first?
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elevate the head of the bed to a semi fowler's positionat during the feeding
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At what rate would the rn set the infusion pump?
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60 ml/hr
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Which intervention should the rn implement first?
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Continue to stay at Mrs. ...
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How should the nurse respond?
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"I am sorry, but i am unable..."
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Which action should the rn implement?
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Explain that Mrs. can only be a tissue donor, not an organ donor
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Which action would be the most import...
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Have a priest perform Mrs. Anointing...
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How should the rn respond?
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"You seem really confused about what..."
