HESI Case Studies – Stroke UPDATED
Exam Questions and CORRECT Answers
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? - Correct Answer- carotid bruit
elevated BP
hyporeflexic DTR
Which assessment finding warrants immediate intervention by the RN? (Select all) - Correct
Answer- Mr. Jones' Glasgow Coma Scale (GCS) score changes from 12 to 9
Mr. Jones has a positive Babinski's reflex bilaterally
Mr. Jones is unable to verbalize responses to the nurse's questions
Due to his deteriorating condition, the neurologist is consulted to see Mr. Jones immediately.
The nurse suspects that Mr. Jones has probably suffered a right-sided stroke. Which clinical
manifestations further support this assessment? - Correct Answer- increased distractibility
visual deficit on left side
spatial-perceptual deficits
paresthesia on left side
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 Mr. Jones and his son for this procedure? - Correct Answer-
Explain procedure requires client to lie completely still
, 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? -
Correct Answer- left hip replacement
Which explanation by the nurse is the most therapeutic response? - Correct 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 nurse respond? - Correct Answer- "I
know this is scary for you. Would you like to sit and talk?"
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). - Correct Answer- 77
170/2.2= 77.27
With a diagnosis of a stroke, which priority intervention should the nurse include in Mr.
Jones' plan of care? - Correct Answer- monitor glucose daily
elevate HOB
assess neuro status every hour
monitor PTT daily
The nurse continues to monitor Mr. Jones' condition closely. Which finding would require
immediate intervention by the nurse? - Correct Answer- Serum glucose is 150
potassium is 3.0
Exam Questions and CORRECT Answers
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? - Correct Answer- carotid bruit
elevated BP
hyporeflexic DTR
Which assessment finding warrants immediate intervention by the RN? (Select all) - Correct
Answer- Mr. Jones' Glasgow Coma Scale (GCS) score changes from 12 to 9
Mr. Jones has a positive Babinski's reflex bilaterally
Mr. Jones is unable to verbalize responses to the nurse's questions
Due to his deteriorating condition, the neurologist is consulted to see Mr. Jones immediately.
The nurse suspects that Mr. Jones has probably suffered a right-sided stroke. Which clinical
manifestations further support this assessment? - Correct Answer- increased distractibility
visual deficit on left side
spatial-perceptual deficits
paresthesia on left side
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 Mr. Jones and his son for this procedure? - Correct Answer-
Explain procedure requires client to lie completely still
, 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? -
Correct Answer- left hip replacement
Which explanation by the nurse is the most therapeutic response? - Correct 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 nurse respond? - Correct Answer- "I
know this is scary for you. Would you like to sit and talk?"
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). - Correct Answer- 77
170/2.2= 77.27
With a diagnosis of a stroke, which priority intervention should the nurse include in Mr.
Jones' plan of care? - Correct Answer- monitor glucose daily
elevate HOB
assess neuro status every hour
monitor PTT daily
The nurse continues to monitor Mr. Jones' condition closely. Which finding would require
immediate intervention by the nurse? - Correct Answer- Serum glucose is 150
potassium is 3.0
