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)
Answer: -acarotid bruit
-elevated blood pressure
-hyporeflexic deep tendon reflexes
2. Which assessment findings warrant immediate intervention by the
nurse? (select all that apply)
Answer: -Mr. Jones' Glasgow Coma Scale (GCS) score changes from12 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 allthat apply)
Answer: -visual field deficit on the left side
-spatial-perceptual deficits
-paresthesia on the left side
-increased distractibility
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, 4. Which intervention should the nurse implement when preparing Mr.
Jonesand his son for this procedure?
Answer: Explain that the procedure requires the client tolie completely still.
5. Which data warrants immediate intervention by the nurse concerting
thisdiagnostic test?
Answer: Left hip replacement
6. Which explanation by the nurse is the most therapeutic response?
Answer: Your father has had a stroke, and the blood supply to the brain has
been compromised.
7. How should the nurse respond?
Answer: I know this is scary for you. Would you like tosit and talk?
8. How many mg of enoxaparin will the nurse administer in each dose?
Answer: 77
9. With a diagnosis of stroke, which priority intervention should the
nurseinclude in Mr. Jones' plan of care? (select all that apply)
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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)
Answer: -acarotid bruit
-elevated blood pressure
-hyporeflexic deep tendon reflexes
2. Which assessment findings warrant immediate intervention by the
nurse? (select all that apply)
Answer: -Mr. Jones' Glasgow Coma Scale (GCS) score changes from12 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 allthat apply)
Answer: -visual field deficit on the left side
-spatial-perceptual deficits
-paresthesia on the left side
-increased distractibility
1/3
, 4. Which intervention should the nurse implement when preparing Mr.
Jonesand his son for this procedure?
Answer: Explain that the procedure requires the client tolie completely still.
5. Which data warrants immediate intervention by the nurse concerting
thisdiagnostic test?
Answer: Left hip replacement
6. Which explanation by the nurse is the most therapeutic response?
Answer: Your father has had a stroke, and the blood supply to the brain has
been compromised.
7. How should the nurse respond?
Answer: I know this is scary for you. Would you like tosit and talk?
8. How many mg of enoxaparin will the nurse administer in each dose?
Answer: 77
9. With a diagnosis of stroke, which priority intervention should the
nurseinclude in Mr. Jones' plan of care? (select all that apply)
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