Pn hesi exit v4 test

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 Correct Answer: a 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. Correct Answer: D 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. Correct Answer: B 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. Correct Answer: C A client's daughter is sitting by her mother's bedside who was recently transferred to the Intermediate Care Unit. She states "I don't understand what a brain attack is. The healthcare provider told me my mother 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 mother?" What is the best response by the nurse? A) "I am sorry, but according to the Health Insurance Portability and Accounting Act (HIPAA), I cannot give you any information." B) "Your mother has had a stroke, and the blood supply to the brain has been blocked." C) "How do you feel about what the healthcare provider said?" D) "I will call the healthcare provider so he/she can talk to you about your mother's serious condition." Correct Answer: B What is the normal range for cardiac output? Correct Answer: 4-8L/min A client was admitted with the diagnosis of a brain attack. Their symptoms began 24 hours before being admitted. Why would this client not be a candidate for for thrombolytic therapy? Correct Answer: Thrombolytic therapy is contraindicated in clients with symptom onset longer than 3 hours prior to admission. This client had symptoms for 24 hours before being brought to the medical center What are plate guards? Correct Answer: Plate guards prevent food from being pushed off the plate. Using plate guards and other assistive devices will encourage independence in a client with a self-care deficit. Which condition is considered a non-modifiable risk factor for a brain attack? A) High cholesterol levels. B) Obesity. C) History of atrial fibrillation. D) Advanced age. Correct Answer: D A client is experiencing homonymous hemianopsia as the result of a brain attack. Which nursing intervention would the nurse implement to address this condition? A) Turn Nancy every two hours and perform active range of motion exercises. B) Place the objects Nancy needs for activities of daily living on the left side of the table. C) Speak slowly and clearly to assist Nancy in forming sounds to words. D) Request that the dietary department thicken all liquids on Nancy's meal and snack trays. Correct Answer: B A physical therapist (PT) places a gait belt on a client and is assisting them with ambulation from the bed to the chair. As they get up out of the bed, they report being dizzy and begin to fall. The PT carefully allows them to fall back to the bed and notifies the primary nurse. Which written documentation should the nurse put in the client's record? A) Client experienced orthostatic hypotension when getting out of bed. B) PT reported client complained of dizziness when getting out of bed, and gait belt was used to allow client to fall back onto the bed. C) PT notified the primary nurse that the client could not ambulate at this time because of dizziness. D) Client had difficulty ambulating from the bed to the chair when accompanied by the PT, variance report completed. Correct Answer: B