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HESI RN EXIT CASE STUDY - STROKE
1. Which additional clinical manifestations should the nurse expect to find if Mr. Jones' symptoms
have been caused by a stroke? (select all that apply) ANS: -a carotid bruit -elevated blood pressure -hyporeflexic deep tendon reflexes
2. Which assessment findings warrant immediate intervention by the nurse? (select all that apply)
ANS: -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
3. What clinical manifestations further support this assessment? (select all that apply)
ANS: -visual field deficit on the left side -spatial-perceptual deficits -paresthesia on the left side -increased distractibility
4. Which intervention should the nurse implement when preparing Mr. Jones and his son for this
procedure? ANS: Explain that the procedure requires the client to lie completely still.
5. Which data warrants immediate intervention by the nurse concerting this diagnostic test?
ANS: Left hip replacement
6. Which explanation by the nurse is the most therapeutic response?
ANS: Your father has had a stroke, and the blood supply to the brain has been compromised.
7. How should the nurse respond?
ANS: I know this is scary for you. Would you like to sit and talk?
8. How many mg of enoxaparin will the nurse administer in each dose?
ANS: 77
9. With a diagnosis of stroke, which priority intervention should the nurse include in Mr. Jones'
plan of care? (select all that apply) ANS: -Monitor PTT daily -Assess neurological status every hour -Keep the head of the bed elevated -Monitor blood glucose levels daily
10. Which finding would require immediate intervention by the nurse? (select all that apply)
ANS: -Mr. Jones' pulse oximeter reading has been 90% for the past 2 hours -Mr. Jones' serum potassium level is 3.0 mEq/L -Mr. Jones' serum glucose is 150
11. Which nursing interventions would be priority at this time? (select all that apply)
ANS: -Monitor level of consciousness -Monitor intake and output hourly
ANS: That procedure is only done with small strokes, not like the one your dad had.
20. Which nursing care task should the nurse delegate to the UAP? (select all that apply)
ANS: -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)
21. Which written documentation should the nurse put in the client's record?-
ANS: PT reported that client stated he felt dizzy and was lowered to the bed assisted by the PT using a gait belt.
22. Which interventions should the nurse implement to prevent joint deformi- ties? (select all that
apply) ANS: -place Mr. Jones in a prone position for 15 minutes at least 4 times a day -place the elbow higher than the shoulder and the wrist higher than the elbow on the affected side -apply splints to the arms and legs at night
23. What action should the nurse implement to address this situation?
ANS: Dis- cuss how to use a communication board with both Mr. Jones and Barry.
24. Which rehabilitation team member is responsible for evaluating Mr. Jones' dysphagia?
ANS: The speech therapist
25. Which intervention should the nurse perform prior to beginning a feed- ing?
ANS: Elevate the head of the bed 30 to 40 degrees.
26. At what rate would the nurse set the infusion pump?
ANS: 75
27. Which intervention should the nurse implement first?
ANS: Continue to stay at Mr. Jones' bedside and hold Barry's hand.
28. How should the nurse respond?
ANS: I am sorry, but I am unable to give you any information.
29. What actions should the nurse implement? (select all that apply)
ANS: -obtain the necessary permits and notify the regional organ donor center -Explain that Mr. Jones can only be a tissue donor, not an organ donor
30. Which action would be most important for the nurse to take in this situa- tion?
ANS: Have a clergy come to pray.
31. How should the nurse respond?
ANS: You seem really confused about what to do. Would you like to talk about it?
