1. An ER nurse is completing an assessment on a patient that is alert but
struggles to answer questions. When she attempts to talk, she slurs her
speech and appears very frightened. What additional clinical manifestation
does the nurse expect to find if nacy's sysmptoms have been caused by a
brain attack (stroke)?
A. A carotid bruit
B. A hypotensive blood pressure
C. hyperreflexic deep tendon relexes.
D. Decreased bowel sounds: A) A carotid bruit.
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, Rationale: the carotid artery (artery to the brain) is narrowed in clients with a
brain attack. A bruit is an abnormal sound heard on auscultation resulting from
interference with normal blood flow. Usually the blood pressure is hypertensive.
Initially flaccid paralysis occurs, resulting in hyporefkexic deep tendon reflexes.
Bowel sounds are not indicative of a brain attack.
2. Which clinical manifestation further supports an assessment of a left-sided
brain attack?
A) Visual field deficit on the left side.
B) Spatial-perceptual deficits.
C) Paresthesia of the left side.
D) Global aphasia.
D) Global aphasia.: D) Global aphasia.
Rationale: Global aphasia refers to difficulty speaking, listening, and understanding,
as well as difficulty reading and writing. Symptoms vary from person to person.
Aphasia may occur secondary to any brain injury involving the left hemisphere.
Visual field deficits, spatial-perceptual deficits, and paresthsia of the left side usually
occur with right-sided brain attack.
mailto:https://www.stuvia.com/user/techgrades
, 3. When preparing a patient for a noncontrast computed tomography (CT)
scan STAT, what nursing intervention should the nurse implement?
A) Determine if the client has any allergies to iodine
B) Explain that the client will not be able to move her head throughout the CT
scan.
C) Premedicate the client to decrease pain prior to having the procedure.
D) Provide an explanation of relaxation exercises prior to the procedure.: B)
Explain that the client will not be able to move her head throughout the CT scan.
mailto:https://www.stuvia.com/user/techgrades
, Rationale: Because head motion will distort the images, Nancy will have to remain
still throughout the procedure. Allergies to iodine is important if contrast dye is
being used for the CT scan. Premedicating the client to decrease pain prior to
the procedure is unnecessary because CT scanning is a noninvasive and painless
procedure. Providing an explanation of relaxation exercises prior to the procedure
is a worthwhile intervention to decrease anxiety but is not of highest priority.
4. A neurologist prescribes a magnetic resonance imaging (MRI) of the head
STAT for a patient. Which data warrants immediate intervention by the nurse
concerning this diagnostic test?
A) Elevated blood pressure.
B) Allergy to shell fish.
C) Right hip replacement.
D) History of atrial fibrillation.: C) Right 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
mailto:https://www.stuvia.com/user/techgrades
struggles to answer questions. When she attempts to talk, she slurs her
speech and appears very frightened. What additional clinical manifestation
does the nurse expect to find if nacy's sysmptoms have been caused by a
brain attack (stroke)?
A. A carotid bruit
B. A hypotensive blood pressure
C. hyperreflexic deep tendon relexes.
D. Decreased bowel sounds: A) A carotid bruit.
mailto:https://www.stuvia.com/user/techgrades
, Rationale: the carotid artery (artery to the brain) is narrowed in clients with a
brain attack. A bruit is an abnormal sound heard on auscultation resulting from
interference with normal blood flow. Usually the blood pressure is hypertensive.
Initially flaccid paralysis occurs, resulting in hyporefkexic deep tendon reflexes.
Bowel sounds are not indicative of a brain attack.
2. Which clinical manifestation further supports an assessment of a left-sided
brain attack?
A) Visual field deficit on the left side.
B) Spatial-perceptual deficits.
C) Paresthesia of the left side.
D) Global aphasia.
D) Global aphasia.: D) Global aphasia.
Rationale: Global aphasia refers to difficulty speaking, listening, and understanding,
as well as difficulty reading and writing. Symptoms vary from person to person.
Aphasia may occur secondary to any brain injury involving the left hemisphere.
Visual field deficits, spatial-perceptual deficits, and paresthsia of the left side usually
occur with right-sided brain attack.
mailto:https://www.stuvia.com/user/techgrades
, 3. When preparing a patient for a noncontrast computed tomography (CT)
scan STAT, what nursing intervention should the nurse implement?
A) Determine if the client has any allergies to iodine
B) Explain that the client will not be able to move her head throughout the CT
scan.
C) Premedicate the client to decrease pain prior to having the procedure.
D) Provide an explanation of relaxation exercises prior to the procedure.: B)
Explain that the client will not be able to move her head throughout the CT scan.
mailto:https://www.stuvia.com/user/techgrades
, Rationale: Because head motion will distort the images, Nancy will have to remain
still throughout the procedure. Allergies to iodine is important if contrast dye is
being used for the CT scan. Premedicating the client to decrease pain prior to
the procedure is unnecessary because CT scanning is a noninvasive and painless
procedure. Providing an explanation of relaxation exercises prior to the procedure
is a worthwhile intervention to decrease anxiety but is not of highest priority.
4. A neurologist prescribes a magnetic resonance imaging (MRI) of the head
STAT for a patient. Which data warrants immediate intervention by the nurse
concerning this diagnostic test?
A) Elevated blood pressure.
B) Allergy to shell fish.
C) Right hip replacement.
D) History of atrial fibrillation.: C) Right 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
mailto:https://www.stuvia.com/user/techgrades
