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HESI Case Studies - Stroke Correct and Verified Answers Graded A
Stroke Case Study Review
- Question
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
Correct Answer:
Potassium is 3.0
- Question
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
Correct Answer:
Assess neuro status every hour
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- Question
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).
Correct Answer:
77
(Calculation: 170 / 2.2 = 77.27, rounded to 77 mg)
- Question
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?
Correct Answer:
"I know this is scary for you. Would you like to sit and talk?"
- Question
Which explanation by the nurse is the most therapeutic response?
Correct Answer:
"Your father has had a stroke, and the blood supply to the brain has been compromised."
- Question
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?
Correct Answer:
Left hip replacement
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- Question
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?
Correct Answer:
Explain procedure requires client to lie completely still
- Question
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?
Correct Answer:
• Increased distractibility • Visual deficit on left side • Spatial-perceptual deficits • Paresthesia on left side
- Question
Which assessment finding warrants immediate intervention by the RN? (Select all)
Correct Answer:
• 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
- Question
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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?
Correct Answer:
• Carotid bruit • Elevated BP • Hyporeflexic DTR
- Question
Over the next 24 hours, 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
Correct Answer:
Monitor intake & output hourly
- Question
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?
Correct Answer:
"He is not a candidate because of therapeutic time constraints related to this medication."
