Upgrade to remove ads
Only $35.99/year

HESI Case Studies - Stroke

Terms in this set (31)

The Emergency Department (ED) nurse completes the admission assessment. Mr. Jones is alert but struggles to answer questions. When he attempts to talk, he slurs his speech and appears very frightened. Which additional clinical manifestations should the nurse expect to find if Mr. Jones' symptoms have been caused by a stroke?
carotid bruit

elevated BP

hyporeflexic DTR
Which assessment finding warrants immediate intervention by the RN? (Select all)
Mr. Jones' Glasgow Coma Scale (GCS) score changes from 12 to 9

Mr. Jones has a positive Babinski's reflex bilaterally

Mr. Jones is unable to verbalize responses to the nurse's questions
Due to his deteriorating condition, the neurologist is consulted to see Mr. Jones immediately. The nurse suspects that Mr. Jones has probably suffered a right-sided stroke. Which clinical manifestations further support this assessment?
increased distractibility

visual deficit on left side

spatial-perceptual deficits

paresthesia on left side
The neurologist writes a diagnosis of "suspected stroke" and prescribes a computed tomography (CT) scan without contrast STAT. Which intervention should the nurse implement when preparing Mr. Jones and his son for this procedure?
Explain procedure requires client to lie completely still
The neurologist also prescribes a magnetic resonance imaging (MRI) of the head STAT. Which data warrants immediate intervention by the nurse concerning this diagnostic test?
left hip replacement
Which explanation by the nurse is the most therapeutic response?
"Your father has had a stroke, and the blood supply to the brain has been compromised."
Barry is visibly upset and states, "Dad has been fine all week. We even went out to dinner. I love him so much and I am scared." How should the nurse respond?
"I know this is scary for you. Would you like to sit and talk?"
The neurologist diagnoses an ischemic right-sided stroke. The neurologist determines that Mr. Jones is not a candidate for tissue plasminogen activator (tPA). Enoxaparin 1 mg/kg subcutaneously every 12 hours is prescribed.Mr. Jones weighs 170 pounds. How many mg of enoxaparin will the nurse administer in each dose? (Enter the numerical value only. If rounding is required, round to the whole number).
77

170/2.2= 77.27
With a diagnosis of a stroke, which priority intervention should the nurse include in Mr. Jones' plan of care?
monitor glucose daily

elevate HOB

assess neuro status every hour

monitor PTT daily
The nurse continues to monitor Mr. Jones' condition closely. Which finding would require immediate intervention by the nurse?
Serum glucose is 150

potassium is 3.0

pulse ox has been 90% for the past two hours
Over the next 24 hour, Mr. Jones' SaO2, potassium level, and telemetry readings are within normal limits for his age, but his cardiac output decreases. The HCP needs to be notified regarding decreased cardiac output to decide whether to initiate IV fluid if hypovolemia is an issue and to determine other medical interventions.Which nursing interventions would be priority at this time?
Monitor LOC

Monitor intake & output hourly

Monitor capillary refill every 2 to 4 hours

Monitor pulse oximetry
As the nurse assesses Mr. Jones, Barry asks, "Why isn't my dad a candidate for thrombolytic therapy?" How should the nurse respond to Barry?
"He is not a candidate because of therapeutic time constraints related to this medication."
Mr. Jones spends 3 days in the Neuro Intensive Care Unit. Once stabilized, he is transferred to a 30-bed medical unit. Mr. Jones has left-sided paralysis, facial drooping with dysphagia, left visual field deficit and aphasia. His IV fluids are discontinued, but he continues with a 20 gauge saline lock, now in the right forearm. He also has an indwelling urinary catheter. The HCP prescribes bedrest and sitting upright in a chair 4 times a day.Which nursing diagnosis has the highest priority?
Impaired swallowing
Which nursing intervention should the nurse implement to address Mr. Jones' self-care deficit?
Use plate guards when Mr. Jones is eating
Barry asks the nurse, "Why did my dad have this stroke? Does this mean I might have a stroke when I get older?" The nurse discusses the difference between modifiable and nonmodifiable risk factors for a stroke.Which conditions are considered a modifiable risk factor for a stroke?
High cholesterol levels

Diet

lifestyle

Hx of atrial fibrillation
Barry tells the nurse that he 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 stroke."
Mr. Jones is experiencing homonymous hemianopsia as the result of his stroke. Which nursing intervention would the nurse implement to address
Place objects needed for ADLs on right side of table
Mr. Jones is experiencing pain in his left shoulder. The nurse is aware that up to 70% of clients with a stroke 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 Mr. Jones to clasp the left hand with the right 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 dad had."
Which nursing care task should the nurse delegate to the UAP? (Select all the apply.)
Take Mr. Jones' vital signs

Give Mr. Jones a bed bath and change the bed linens

Measure Mr. Jones' intake and output each shift (I&O)
A physical therapist (PT) places a gait belt on Mr. Jones and assists him with ambulation from the bed to the chair. As he gets up out of the bed, Mr. Jones says he is dizzy and begins to fall. The PT carefully allows him to fall back to the bed and notifies the primary nurse. Which written documentation should the nurse put in the client's record?
PT reported that client stated he felt dizzy and was lowered to the bed assisted by the PT using a gait belt.
Which interventions should the nurse implement to prevent joint deformities?
Apply splints the arms and legs at night

Place the elbow higher than the shoulder and the wrist higher than the elbow on the affected side

Place in prone position for 15 min for at least 4 times a day
What action should the nurse implement to address this situation?
discuss how to use a communication board with Mr. Jones and Barry
Which rehabilitation team member is responsible for evaluating Mr. Jones' dysphagia?
speech therapist
Which intervention should the nurse prior to beginning a feeding?
Elevate HOB to 30 or 40 degrees
The HCP orders 360 mL of liquid nourishment diluted with one can of water to be infused over 8 hours. The feeding will be administered through an infusion pump, which infuses in mL/hr. At what rate would the nurse set the infusion pump? (Enter numerical value only. If rounding is necessary, round to the whole number.)
75

360 ml + 240 ml (8 oz x 30 ml)= 600 ml/8 hrs= 75 ml/hr
Which intervention should the nurse implement first?
continue to stay at bedside and hold Barry's hand
How should the nurse respond?
"I am sorry, but I am unable to give you any information."
What actions should the nurse implement?
Explain that Mr. Jones can only be a tissue donor, not an organ donor

Obtain necessary permits and notify the organ donor center
Which action would be most important for the nurse to take in this situation?
have clergy come pray
How should the nurse respond?
"You seem really confused about what to do. Would you like to take about it?"
Students also viewed