HESI Case Studies – Brain Attack (Stroke)

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