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HESI RN EXIT CASE STUDY - STROKE
1. The Emergency Department (ED) nurse completes the admission assess- ment. 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 ANS: carotid bruit elevated BP hyporeflexic DTR
2. Which assessment finding warrants immediate intervention by the RN?
ANS: (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
3. 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 assess- ment ANS: increased distractibility visual deficit on left side spatial- perceptual deficits paresthesia on left side
4. 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 ANS: Explain procedure requires client to lie completely still
5. 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 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. 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 ANS: "I know this is scary for you. Would you like to sit and talk?"
8. The neurologist diagnoses an ischemic right-sided stroke. The neurologist determines that Mr.
Jones is not a candidate for tissue plasminogen activator
Monitor capillary refill every 2 to 4 hours Monitor pulse oximetry
12. As the nurse assesses Mr. Jones, Barry asks, "Why isn't my dad a candi- date for thrombolytic
therapy?" How should the nurse respond to Barry ANS: "He is not a candidate because of therapeutic time constraints related to this medication."
13. 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 ANS: Impaired swallowing
14. Which nursing intervention should the nurse implement to address Mr. Jones' self-care deficit
ANS: Use plate guards when Mr. Jones is eating
15. 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 con- ditions are considered a modifiable risk factor for a stroke ANS: High cholesterol levels Diet lifestyle Hx of atrial fibrillation
16. 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 ANS: "I should let you know that smoking is a strong risk factor for a stroke."
17. Mr. Jones is experiencing homonymous hemianopsia as the result of his stroke. Which nursing
intervention would the nurse implement to address: ANS: - Place objects needed for ADLs on right side of table
18. 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 activi- ties.Which intervention should the nurse implement when addressing this condition ANS: Instruct Mr. Jones to clasp the left hand with the right hand and raise both hands above the head.
19. How should the nurse respond
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 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)
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 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
ANS: 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
23. What action should the nurse implement to address this situation
ANS: discuss how to use a communication board with Mr. Jones and Barry
24. Which rehabilitation team member is responsible for evaluating Mr. Jones' dysphagia
ANS: speech therapist
25. Which intervention should the nurse prior to beginning a feeding
ANS: Elevate HOB to 30 or 40 degrees
26. 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
27. Which intervention should the nurse implement first
ANS: continue to stay at 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
ANS: Explain that Mr. Jones can only be a tissue donor, not an organ donor
Obtain necessary permits and notify the organ donor center
30. Which action would be most important for the nurse to take in this situa- tion
ANS: have clergy come pray
31. How should the nurse respond
ANS: "You seem really confused about what to do. Would you like to take about it?"
