HESI RN Case Studies-Brain Attack (Stroke)

Which additional clinical manifestation(s) should the RN expect…
-A cardiac bruit
-Elevated blood pressure
-Drooling

Which assessment finding warrants immediate intervention by the RN? …
-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

Which clinical manifestation further supports this assessment?
Global aphasia

Which intervention should the RN implement when preparing Mrs. and her daughter…
Explain to the daughter that her mother will have to remain still throughout the ct scan

Which data warrants immediate intervention by the nurse concerning…
right hip replacement

Which is the best response by the rn?
“Your mother has had a stroke, and the blood supply to the brain has been compromised”

How should the rn respond?
“I know this is scary for you. Would you like to sit and talk?”

Mrs. weighs 145 Ibs. How many mg of enoxaparin will the nurse administer in each dose?
66

With a diagnosis of a brain attack (stroke), which priority intervention…
Keep the head of the bed elevated

Which finding would require immediate intervention by the rn?
Mrs.’s cardiac output is less than 4 L/min

Which nursing interventions would be priority at this time?
-Monitor level of consciousness
-Strictly monitor intake and output
-Monitor capillary refill every 2-4 hrs
-Contact physician

How should the rn respond to Gail?
“She is not a candidate because of the therapeutic time constraints related to this medication”

Which nursing diagnosis has the highest priority?
Drooling

Which nursing intervention would the rn implement to address…
Use plate guards when Mrs. Jackson is eating

Which condition is considered a modifiable risk factor for a brain attack?
-High cholesterol levels
-Obesity
-Hypertension
-History of atrial fibrillation

Which statement is warranted in this situation?
“I should let you know that smoking is a strong risk factor for a brain attack”

Which nursing intervention would the rn implement to address this condition?
Place the objects Mrs. needs for activities of daily living on the left side of the table

Which intervention should the rn implement when addressing this condition?
Instruct Mrs. to clasp the right hand with the left hand and raise both hands above the head

How should the rn respond?
“That procedure is only done with small strokes, not like…

Which nursing care task should the rn delegate to the UAP?
Give Mrs. a bed bath and change the bed linens

Which written documentation should the rn put in the client’s record?
PT reported that client became dizzy and was lowered back to the bed with the assistance of a gait belt

Which intervention should the rn implement to prevent joint deformities?
Place Mrs. in a prone position for 15 minutes at least 4 times a day

What action should the rn implement to address this situation?
Discuss how to use a communication board with both Mrs. and her daughter

Which rehabilitation team member is responsible for evaluating Mrs.’s dysphagia?
The speech therapist

Which intervention should the rn implement first?
elevate the head of the bed to a semi fowler’s positionat during the feeding

At what rate would the rn set the infusion pump?
60 ml/hr

Which intervention should the rn implement first?
Continue to stay at Mrs. …

How should the nurse respond?
“I am sorry, but i am unable…”

Which action should the rn implement?
Explain that Mrs. can only be a tissue donor, not an organ donor

Which action would be the most import…
Have a priest perform Mrs. Anointing…

How should the rn respond?
“You seem really confused about what…”