HESI Case Study: Stroke
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." 1 / 2
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?
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