NU371 HESI Case Study: Stroke week 4 with complete solution

NU371 HESI Case Study: Stroke week 4 with complete solution Meet the Client - Client, a 72-year-old male widower, lives with his son. Client tells his son that he has a headache and that he is not feeling well. Son notices some left-sided weakness in his father and takes client to the Emergency Department (ED). The ED RN completes the full admission assessment and the assigned PN is present. Client 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 client's symptoms have been caused by a stroke? (Select all that apply. One, some, or all options may be correct.) a) Hyperglycemia. b) Elevated blood pressure. c) Arrhythmias. d) Amblyopia e) Difference in temperature of upper and lower extremities. - a) Hyperglycemia. b) Elevated blood pressure. c) Arrhythmias. - Hyperglycemia (elevated blood sugar) may represent the body's stress response during a stroke and has been shown to contribute to brain damage and more severe outcomes.When a client has a stroke, the blood pressure will often respond by increasing. Increased blood pressure is also a sign of increased intracranial pressure and could signal worsening of brain tissue damage.Cardiac rhythms may become abnormal after a stroke. Continuous cardiac monitoring is recommended to monitor ischemic heart changes and abnormal rhythms like atrial fibrillation. Following the ED healthcare provider's (HCP) assessment, the nurse continues to do focused assessments on the client every 15 minutes. Client's son sits at the bedside while the nurse assesses his father. Which assessment findings warrant immediate intervention by the nurse? (Select all that apply. One, some or all options may be correct.) a) Client's Glasgow Coma Scale (GCS) score changes from 12 to 9. b) Client's motor strength is unequal. c) Client responds to painful stimuli. d) Client has a positive Babinski's reflex bilaterally. e) Client is unable to verbalize responses to the nurse's questions. - a) Client's Glasgow Coma Scale (GCS) score changes from 12 to 9. d) Client has a positive Babinski's reflex bilaterally. e) Client is unable to verbalize responses to the nurse's questions. Due to his deteriorating condition, the neurologist is consulted to immediately see client. The nurse suspects that client has probably suffered a right-sided stroke. Which clinical manifestations further support this assessment? (Select all that apply. One, some or all options may be correct.) a) Visual field deficit on the left side. b) Spatial-perceptual deficits. c) Full or partial paralysis of the left side: hemiplegia. d) Increased distractibility and attention span. e) Global aphasia. - a) Visual field deficit on the left side. b) Spatial-perceptual deficits. c) Full or partial paralysis of the left side: hemiplegia. d) Increased distractibility and attention span. 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 client and his son for this procedure? a) Determine if the client has any allergies to iodine or shellfish. b) Explain that the procedure requires the client to lie completely still. c) Offer client an anxiolytic prior to the procedure. d) Ensure that client does not have on any material that is metal, this includes metal prosthesis. - b) Explain that the procedure requires the client to lie completely still. - Because head motion will distort the images, client will have to remain still throughout the procedure. Since client has a decreased level of consciousness (LOC), he may require head support to accomplish this. 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? a) Elevated heart rate. b) Allergy to iodine. c) Left hip replacement. d) History of hypertension. - c) Left hip replacement. - The magnetic field generated by the MRI is so strong that metal-containing items are strongly attracted to the magnet. Because the hip joint is made of metal, a lead shield must be used during the procedure. Therapeutic Communication - Client is transferred to the Neurological Intensive Care Unit (ICU) after the MRI is completed. He has a 20 gauge saline lock in his right forearm and an 18 French indwelling urinary catheter. His son is sitting by his father's bed. The nurse asks the son if there is anyone who can be called so he won't be alone. He informs the nurse that his mother died 2 years ago and his closest relative is a cousin who lives out of state. The son states, "I don't understand what a stroke is. The HCP told me that my father is in serious condition and they are going to run several tests. I just don't know what is going on. What happened to my father?" Which explanation by the nurse is the most therapeutic response? a) "I am sorry, that information is protected by HIPAA." b) "Your father has had a stroke, and the blood supply to the brain has been compromised." c) "Why didn't you ask the HCP any questions?" d) "You can access information from the internet by using your cell phone." - b) "Your father has had a stroke, and the blood supply to the brain has been compromised." - The nurse has the knowledge and the responsibility, to explain client's condition to the son. The son 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? a) "I wouldn't worry if I were you, I am sure things be ok." b) "I know this is scary for you. Would you like to sit and talk?" c) "I can call your pastor to come and sit with you so you won't be alone." d) "Hang in there. Can you call a friend to come and sit with you until you feel better?" - b) "I know this is scary for you. Would you like to sit and talk?" - This therapeutic response provides acknowledgment of the son's concerns, and the nurse offers to take time to discuss the situation. 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). - 170 lbs/2.2 kg = 77 kg 1 mg/kg x 77 kg= 77 mg With a diagnosis of a stroke, which priority interventions should the nurse implement from the client's plan of care? (Select all that apply. One, some or all options may be correct.)