HESI Case Studies–Medical/Surgical-Brain Attack (Mrs. Jackson)

1. 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)
-A carotid bruit
-Elevated blood pressure
-Drooling
2. Which assessment finding warrants immediate intervention by the RN? (Select all)
-Mrs. Jackson only responds to painful stimuli
-Mrs. Jackson has a positive Babinski’s reflex bilaterally
-Mrs. Jackson’s pupils are reacting unequally, and she is experiencing sensitivity to light
3. What clinical manifestation further supports this assessment?
Global aphasia
4. Which intervention should the RN implement when preparing Mrs. Jackson and her daughter for this procedure?
Explain to the daugther that her mother will have to remain still throughout the CT scan
5. 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?
Right hip replacement

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6. 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?
“Your mother has had a stroke, and the blood supply to the brain has been compromised.”
7. 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?
“I know this is scary for you. Would you like to sit and talk?”
8. 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?
66
9. With a diagnosis of a brain attack, stroke, which priority intervention should the RN include and Mrs. Jackson’s plan of care?
Keep the head of the bed elevated
10. The nurse continues to monitor Nancy’s condition closely. Which finding would require immediate intervention by the nurse?
Mrs. Jackson’s cardiac output is less than 4 L/min
11. 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? (Select all)
-Monitor level of consciousness
-Strictly monitor intake and output
-Monitor capillary refill every 2-4 hours
-Contact physician
12. As the nurse assesses Nancy, Gail asks, “Why isn’t my mother a candidate for thrombolytic therapy?”
“She is not a candidate because of therapeutic time constraints related to this medication.”
13. Which nursing diagnosis has the highest priority?
Drooling
14. 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?
Use plate guards when Mrs. Jackson is eating
15. Which condition is considered a modifiable risk factor for a brain attack? (Select all)
-High cholesterol levels
-Obesity
-Hypertension
-History of atrial fibrillation
16. 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?
“I should let you know that smoking is a strong risk factor for a brain attack.”
17. Nancy is experiencing homonymous hemianopsia as a result of her brain attack. Which nursing intervention would the nurse implement address this condition?
Place the objects Mrs. Jackson needs for activities of daily living on the left side of the table
18. 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?
Instruct Mrs. Jackson to clasp the right hand with the left hand and raise both hands above the head
19. 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?
“That procedure is only done with small strokes, not like the one your mom had.”
20. Which nursing care task should the nurse delegate to the UAP?
Give Mrs. Jackson a bed bath and change the bed linens
21. Which written documentation should the nurse put in the client’s record?
PT reported that client became dizzy and was lowered back to bed with the assistance of a gait belt
22. Which intervention should the nurse implement to prevent joint deformities?
Place Mrs. Jackson in a prone position for 15 minutes at least 4 times a day
23. Which action should the RN implement to address this situation?
Discuss how to use a communication board with both Mrs. Jackson and her daughter
24. Which rehabilitation team member is responsible for evaluating Mrs. Jackson’s dysphagia?
The speech therapist
25. 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?
Elevate the head of the bed to a semi fowler’s position during the feeding
26. At what rate would the RN set the infusion pump?
60 mL/hr
27. The RN assesses Mrs. Jackson’s apical pulse but cannot hear anything. Which intervention should the RN implement first?
Continue to stay at Mrs. Jackson’s bedside and hold Gail’s hand
28. 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?
“I am sorry, but I am unable to give you any information.”
29. 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?
Explain that Mrs. Jackson can only be a tissue donor, not an organ donor
30. 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?
Have a priest perform Mrs. Jackson 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?
“You seem really confused about what to do. Would you like to talk about it?”
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