NU371 HESI Case Study: Stroke (week 4) Questions With
Complete Solutions
A physical therapist (PT) places a gait belt on client and assists
him with ambulation from the bed to the chair. As he gets up out
of the bed, client says he is dizzy and begins to fall. The PT
carefully allows him 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 that client stated he felt dizzy and was lowered to
the bed assisted by the PT using a gait belt.
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 Answers b) PT reported that client stated he felt dizzy
and was lowered to the bed assisted by the PT using a gait belt.
-
This documentation provides the factual data of the events that
occurred.
As the nurse assesses client, his son asks, "Why isn't my dad a
candidate for thrombolytic therapy?" How should the nurse
respond?
a) "I think that is something you should discuss with your
father's HCP."
b) "He is not a candidate because of therapeutic time constraints
related to this medication."
,c) "Thrombolytic therapy is usually not administered to anyone
older than 65 years."
d) "Since your father was alert on admission, he is not a
candidate to receive this medication." Correct Answers b) "He
is not a candidate because of therapeutic time constraints related
to this medication."
-
Thrombolytic therapy is contraindicated in clients with symptom
onset longer than 3 hours prior to admission. Client had
symptoms for 24 hours before being brought to the ED.
Because client is left-handed and is having difficulty performing
activities of daily living with his left arm, the nurse knows that
another important nursing problem for client is his inability to
care for himself. The PN nurse discusses this with the RN
charge nurse for inclusion in the problem list so appropriate
goals and interventions can be added by the RN. Correct
Answers -
Client appears depressed, and the son reports that his father
seems to have lost all hope. He reminds the staff that his father
has a Living Will and a Do Not Resuscitate (DNR), or Allow
Natural Death (AND) order. Client has a Durable Power of
Attorney for Health Care that was signed more than 2 years ago.
Correct Answers Two weeks later, the son is sitting at the
bedside when client starts to gasp for air. The son rings the call
light and also yells for help. When the nurse arrives, client is not
breathing. The nurse assesses his apical pulse but cannot hear
anything.
, Client has difficulty communicating with the rehabilitation team
and his son is very upset that his father can't communicate. The
son tells the nurse that client has always been an eloquent
speaker. The son has been helping his father by answering
questions for him and trying to anticipate his needs. Correct
Answers -
Client is experiencing homonymous hemianopsia as the result of
his stroke. Which nursing intervention would the nurse
implement to address this condition?
a) Ensure that client sits in the chair four times a day.
b) Place the objects client needs for activities of daily living on
the right side of the table.
c) Use a communication board when conversing with client.
d) Reorient client to time, place and situation during nursing
interventions. Correct Answers b) Place the objects client
needs for activities of daily living on the right side of the table.
-
Homonymous hemianopsia is loss of the visual field blindness
in the same half of each visual field. This results in the client
neglecting that side of the body, so it is beneficial to place
objects on that side. Client had a right-hemisphere stroke so his
left side is the weak side.
Client is experiencing pain in his left shoulder. The nurse is
aware that up to 70% of clients with a stroke experience severe
pain in the shoulder that prevents them from learning new skills.
Shoulder function helps clients achieve balance, perform
transfer skills, and participate in self-care activities. Correct
Answers -
Complete Solutions
A physical therapist (PT) places a gait belt on client and assists
him with ambulation from the bed to the chair. As he gets up out
of the bed, client says he is dizzy and begins to fall. The PT
carefully allows him 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 that client stated he felt dizzy and was lowered to
the bed assisted by the PT using a gait belt.
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 Answers b) PT reported that client stated he felt dizzy
and was lowered to the bed assisted by the PT using a gait belt.
-
This documentation provides the factual data of the events that
occurred.
As the nurse assesses client, his son asks, "Why isn't my dad a
candidate for thrombolytic therapy?" How should the nurse
respond?
a) "I think that is something you should discuss with your
father's HCP."
b) "He is not a candidate because of therapeutic time constraints
related to this medication."
,c) "Thrombolytic therapy is usually not administered to anyone
older than 65 years."
d) "Since your father was alert on admission, he is not a
candidate to receive this medication." Correct Answers b) "He
is not a candidate because of therapeutic time constraints related
to this medication."
-
Thrombolytic therapy is contraindicated in clients with symptom
onset longer than 3 hours prior to admission. Client had
symptoms for 24 hours before being brought to the ED.
Because client is left-handed and is having difficulty performing
activities of daily living with his left arm, the nurse knows that
another important nursing problem for client is his inability to
care for himself. The PN nurse discusses this with the RN
charge nurse for inclusion in the problem list so appropriate
goals and interventions can be added by the RN. Correct
Answers -
Client appears depressed, and the son reports that his father
seems to have lost all hope. He reminds the staff that his father
has a Living Will and a Do Not Resuscitate (DNR), or Allow
Natural Death (AND) order. Client has a Durable Power of
Attorney for Health Care that was signed more than 2 years ago.
Correct Answers Two weeks later, the son is sitting at the
bedside when client starts to gasp for air. The son rings the call
light and also yells for help. When the nurse arrives, client is not
breathing. The nurse assesses his apical pulse but cannot hear
anything.
, Client has difficulty communicating with the rehabilitation team
and his son is very upset that his father can't communicate. The
son tells the nurse that client has always been an eloquent
speaker. The son has been helping his father by answering
questions for him and trying to anticipate his needs. Correct
Answers -
Client is experiencing homonymous hemianopsia as the result of
his stroke. Which nursing intervention would the nurse
implement to address this condition?
a) Ensure that client sits in the chair four times a day.
b) Place the objects client needs for activities of daily living on
the right side of the table.
c) Use a communication board when conversing with client.
d) Reorient client to time, place and situation during nursing
interventions. Correct Answers b) Place the objects client
needs for activities of daily living on the right side of the table.
-
Homonymous hemianopsia is loss of the visual field blindness
in the same half of each visual field. This results in the client
neglecting that side of the body, so it is beneficial to place
objects on that side. Client had a right-hemisphere stroke so his
left side is the weak side.
Client is experiencing pain in his left shoulder. The nurse is
aware that up to 70% of clients with a stroke experience severe
pain in the shoulder that prevents them from learning new skills.
Shoulder function helps clients achieve balance, perform
transfer skills, and participate in self-care activities. Correct
Answers -
