(Graded) Stroke HESI Case Study Mr. Hubert Jones, a 72 -year-old African American male widower, lives with his son, Barry Jones. Mr. Jones tells his son that he has a headache and that he is not feeling well. Barry notices some left -
sided weakness in his father and 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? Answer - carotid bruit elevated BP hyporeflexic DTR Following the ED healthcare provider's (HCP) assessment, the ED nurse continues to assess Mr. Jones every 15 minutes. Mr. Jones' son, Barry sits at the bedside while the nurse assess Mr. Jones. Which assessment findings warrant immediate intervention by the nurse? Answer - GCS changes from 12 to 9 positive Babinski's reflex bilaterally unable to verbalize response to questions Due to his deteriorating condition, the neurologist is consulted to see Mr. Jones immediately. The nurse suspects that Mr. Jones ha s probably suffered a right -sided stroke. Which clinical manifestations further support this assessment? Answer - increased distractibility visual deficit on left side spatial -perceptual deficits paresthesia on left side (global aphasia L hemi) The neuro logist 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? Answer - Explain procedure requires client to lie completely still (head motion will distort the images, if his LOC is decreased he may require a head support to accomplish this) The neurologist also prescribes a magnetic resonance imaging (MRI) of the head STAT. Which data warrants immed iate intervention by the nurse concerning this diagnostic test? Answer - left hip replacement Over the next 24 hour, 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 i f hypovolemia is an issue and to determine other medical interventions.Which nursing interventions would be priority at this time? Answer - monitor pulse ox, capillary refill, intake and output, and LOC Which explanation by the nurse is the most therapeut ic response?Answer - "Your father has had a stroke, and the blood supply to the brain has been compromised." 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 nu rse respond? Answer - "I know this is scary for you. Would you like to sit and talk?" Which nursing care task should the nurse delegate to the UAP? (Select all the apply.) Answer - measure I&Os change linen and give bed bath take vital signs With a diagn osis of a stroke, which priority intervention should the nurse include in Mr. Jones' plan of care? Answer - monitor glucose daily elevate head of bed assess neuro status daily monitor PTT daily 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 numbe r.) Answer - 360 ml + 240 ml (8 oz x 30 ml)= 600 ml/8 hrs= 75 ml/hr What actions should the nurse implement?Answer - Explain that Mr. Jones can only be a tissue donor, not an organ donor Obtain necessary permits and notify the organ donor center The neur ologist diagnoses an ischemic right -sided stroke. The neurologist determines that Mr. Jones is not a candidate for tissue plasminogen activator (tPA). Enoxaparin 1
sided weakness in his father and 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? Answer - carotid bruit elevated BP hyporeflexic DTR Following the ED healthcare provider's (HCP) assessment, the ED nurse continues to assess Mr. Jones every 15 minutes. Mr. Jones' son, Barry sits at the bedside while the nurse assess Mr. Jones. Which assessment findings warrant immediate intervention by the nurse? Answer - GCS changes from 12 to 9 positive Babinski's reflex bilaterally unable to verbalize response to questions Due to his deteriorating condition, the neurologist is consulted to see Mr. Jones immediately. The nurse suspects that Mr. Jones ha s probably suffered a right -sided stroke. Which clinical manifestations further support this assessment? Answer - increased distractibility visual deficit on left side spatial -perceptual deficits paresthesia on left side (global aphasia L hemi) The neuro logist 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? Answer - Explain procedure requires client to lie completely still (head motion will distort the images, if his LOC is decreased he may require a head support to accomplish this) The neurologist also prescribes a magnetic resonance imaging (MRI) of the head STAT. Which data warrants immed iate intervention by the nurse concerning this diagnostic test? Answer - left hip replacement Over the next 24 hour, 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 i f hypovolemia is an issue and to determine other medical interventions.Which nursing interventions would be priority at this time? Answer - monitor pulse ox, capillary refill, intake and output, and LOC Which explanation by the nurse is the most therapeut ic response?Answer - "Your father has had a stroke, and the blood supply to the brain has been compromised." 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 nu rse respond? Answer - "I know this is scary for you. Would you like to sit and talk?" Which nursing care task should the nurse delegate to the UAP? (Select all the apply.) Answer - measure I&Os change linen and give bed bath take vital signs With a diagn osis of a stroke, which priority intervention should the nurse include in Mr. Jones' plan of care? Answer - monitor glucose daily elevate head of bed assess neuro status daily monitor PTT daily 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 numbe r.) Answer - 360 ml + 240 ml (8 oz x 30 ml)= 600 ml/8 hrs= 75 ml/hr What actions should the nurse implement?Answer - Explain that Mr. Jones can only be a tissue donor, not an organ donor Obtain necessary permits and notify the organ donor center The neur ologist diagnoses an ischemic right -sided stroke. The neurologist determines that Mr. Jones is not a candidate for tissue plasminogen activator (tPA). Enoxaparin 1
