HESI- Brain Attack (Stroke)
Which additional clinical manifestations should the RN expect to find if these symptoms Mrs. Jackson has have been caused by a brain attack (stroke)? (Select all that apply)
A. Carotid bruit
B. Elevated BP
Which assessment finding warrants immediate intervention by the RN? (Select all that apply)
C. Mrs. Jackson only response to painful stimuli
D. Positive Babinski’s reflex bilaterally
E. Pupils are reacting unequally, and she is experiencing sensitivity to light
What clinical manifestation further supports this assessment?
D) Global aphasia.
Rationale: Global aphasia refers to difficulty speaking, listening, and understanding, as well as difficulty reading and writing. Symptoms vary from person to person. Aphasia may occur secondary to any brain injury involving the left hemisphere. Visual field deficits, spatial-perceptual deficits, and paresthsia of the left side usually occur with right-sided brain attack.
Which intervention should the RN implement when preparing Mrs. Jackson and her daughter for this procedure?
B) Explain to the daughter that her mother will have to remain still throughout the CT scan.
Rationale: Because head motion will distort the images, Nancy will have to remain still throughout the procedure. Allergies to iodine is important if contrast dye is being used for the CT scan. Premedicating the client to decrease pain prior to the procedure is unnecessary because CT scanning is a noninvasive and painless procedure. Providing an explanation of relaxation exercises prior to the procedure is a worthwhile intervention to decrease anxiety but is not of highest priority.
A neurologist prescribes a magnetic resonance imaging (MRI) of the head STAT for a patient. Which data warrants immediate intervention by the nurse concerning this diagnostic test?
C) Right 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. Elevated blood pressure, an allergy to shell fish, and a history of atrial fibrillation would not affect the MRI.
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Gail, the daughter states, “I don’t understand what a brain attack is. The healthcare provider told me my mother 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 mother?” What is the best response by the nurse?
B) “Your mother has had a stroke, and the blood supply to the brain has been blocked.”
Rationale: The nurse can discuss what a diagnosis means. Nancy is unable to make decisions, so the next of kin, her daughter, Gail, needs sufficient information to make informed decisions. The nurse has the knowledge, and the responsibility, to explain Nancy’s condition to Gail. The nurse should give facts first, and then address her feelings after the information is provided.
Gail begins to cry and states, “Mom was just fine last week when we went out to eat and to a show. I love my mom so much, and I am so scared. She is all I have.” How should the RN respond?
B. I know this is scary for you. Would you like to sit and talk?
The neurologist diagnosis I’d ask you make a left sided brain attack, stroke. The neurologist determines that Mrs. Jackson is not a candidate for tissue plasminogen activator, tPA. Enoxaparin 1 mg/kg subcutaneously every 12 hours is prescribed. Mrs. Jackson weighs 145 pounds. How many milligrams of Enoxaparin Will the nurse administer in each dose?
145/2.2 = 65.9kg x 1mg/kg = approx. 66 mg
With a diagnosis of a brain attack, stroke, which priority intervention should the RN include and Mrs. Jackson’s plan of care?
C. Keep the head of the bed elevated
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.
The nurse continues to monitor Nancy’s condition closely. Which finding would require immediate intervention by the nurse?
A. Nancy’s cardiac output is less than 4 L/min
The normal range for cardiac output to ensure cerebral blood flow and oxygen delivery is 4 to 8 L/min.
Though Nancy’s SaO2 potassium level, and telemetry readings are within normal limits for her age, her cardiac output is low. Which nursing interventions would be priority at this time?
A. Monitor level of consciousness
With a decreased cardiac output, cerebral perfusion will be affected. This can be reflected in a further decreased level of consciousness.
C. Strict intake and output
The kidneys use 25% of cardiac output, so when cardiac output is decreased, the kidneys may start failing. Close monitoring is essential.
D. Monitor capillary refill every 2-4 hours
Decreased cardiac output would affect tissue perfusion, reflected in a capillary refill of greater than 3 seconds.
E. Contact physician
The physician needs to be notified regarding decreased cardiac output to decide whether to initiate IV fluids if hypovolemia is an issue and to determine other medical interventions.
As the nurse assesses Nancy, Gail asks, “Why isn’t my mother a candidate for thrombolytic therapy?”
B. “She 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. Nancy had symptoms for 24 hours before being brought to the medical center.
Which nursing diagnosis has the highest priority?
According to Maslow’s Hierarchy of Needs, physiological needs should be addressed first. Therefore, Nancy’s dysphagia is the highest priority nursing diagnosis since she is at risk for aspiration.
Because Nancy is right-handed and is having difficulty performing activities of daily living with the left arm, the nurse also includes the nursing diagnosis “self-care deficit” in the care plan. Which intervention would the nurse implement to address this nursing diagnosis?
B. Utilize plate guards when Nancy 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 a self-care deficit.
Which condition is considered a modifiable risk factor for a brain attack?
A. High cholesterol levels
D. Hx of A.fib
Gail tells the nurse she 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?
A. “I should let you know that smoking is a strong risk factor for a brain attack.”
The nurse should teach Gail that smoking is a modifiable risk factor that could prevent her from having a stroke. Smoking increases the risk for hypertension, which is a risk factor for a stroke.
Nancy is experiencing homonymous hemianopsia as a result of her brain attack. Which nursing intervention would the nurse implement address this condition?
B. Place the objects Nancy needs for activities of daily living on the left side of the table.
Homonymous hemianopsia is loss of the visual field on the same side as the paralyzed side. This results in the client neglecting that side of the body, so it is beneficial to place objects on that side. Nancy had a left-hemisphere brain attack so her right side is the weak side.
Mrs. Jackson is experiencing pain in her right shoulder. The nurse is aware that up to 70% of clients with a brain attack 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.Which intervention should the nurse implement when addressing this condition?
D. Instruct Mrs. Jackson to clasp the right hand with the left 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.
Gail 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?” How should the RN respond?
B. “That procedure is only done with small strokes,not like the one your Mom 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 nursing care task should the nurse delegate to the UAP?
D. Give Mrs. Jackson a bed bath and change the bed linens
The UAP can assist Nancy with bathing and then change the bed linens. This task does not require professional judgment or expertise
Which written documentation should the nurse put in the client’s record?
B. PT reported that client became dizzy and was lowered back to the bed with the assistance of a gait belt
– This documentation provides the factual data of the events that occurred.
Which intervention should the nurse implement to prevent joint deformities?
A. Place Nancy in a prone position for 15 minutes at least 4 times a day
This helps to promote hyperextension of the hip joints, which helps prevent knee and hip flexion contractures.
Which action should the RN implement to address this situation?
C. Discuss how to use a communication board w/ both Mrs. Jackson and her daughter.
Which rehabilitation team member is responsible for evaluating Mrs. Jackson’s dysphagia?
B. The speech therapist
The speech therapist evaluates the e client’s gag reflex and ability to swallow, then makes recommendations regarding feeding techniques and diet.
The RN notes that Mrs. Jackson is no longer able to meet her nutritional needs and has lost 10 lbs.A gastrostomy tube is prescribed so that intermittent tube feedings can be administered. Which intervention should the RN implement first?
A. Elevate the head of the bed to a semi-fowler’s position during the feeding.
At what rate would the RN set the infusion pump?
B. 60 ml/hr
The RN assesses Mrs. Jackson’s apical pulse but cannot hear anything. Which intervention should the RN implement first?
B. Continue to stay at Mrs. Jackson’s bedside and hold Gail’s hand.
The telephone at Mrs. Jackson’s bedside starts ringing. The RN answers the phone. The caller is one of Mrs. Jackson’s neighbors, wanting to know how Mrs. Jackson is doing. How should the nurse respond?
C. I am sorry, but I am unable to give you any information
The RN remains with Gail at Mrs. Jackson bedside. The HCP is called an pronounces Mrs. Jackson’s death. Gail tells the RN that Mrs. Jackson wanted to be in organ donor. Which action should the RN implement?
B. Explain that Mrs. Jackson can only be a tissue donor, not an organ donor.
Mrs. Jackson was a Roman Catholic so Gail ask for the RN if Mrs. Jackson can receive, the sacrament for the sick. Which action would be most important for the RN to take in the situation?
B. Have a priest perform Mrs. Jackson’s anointing of the sick
Gail wants to bury her mother beside her father in the local cemetery and tells the RN, I just don’t know what I should do. How should the RN respond?
C. You seem really confused about what to do. Would you like to talk about it?