Hesi Case Study on Evolve for
Medical Surgical Strokes
Comprehensive Questions
(Frequently Tested) with
Verified Answers Graded A+
Client, a 72-year-old male widower, lives with his son. Client tells his son that he has a headache
and that he is not feeling well. Son notices some left-sided weakness in his father and takes
client to the Emergency Department (ED). - Answer: The case study
The ED RN completes the full admission assessment and the assigned PN is present. Client 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 client's symptoms have been caused by a stroke? (Select all that apply. One, some, or all
options may be correct.) - Answer: - Hyperglycemia.
Rationale: Hyperglycemia (elevated blood sugar) may represent the body's stress response
during a stroke and has been shown to contribute to brain damage and more severe outcomes.
- Elevated blood pressure.
Rationale: When a client has a stroke, the blood pressure will often respond by increasing.
Increased blood pressure is also a sign of increased intracranial pressure and could signal
worsening of brain tissue damage.
- Arrhythmias.
Cardiac rhythms may become abnormal after a stroke. Continuous cardiac monitoring is
recommended to monitor ischemic heart changes and abnormal rhythms like atrial fibrillation.
, Following the ED healthcare provider's (HCP) assessment, the nurse continues to do focused
assessments on the client every 15 minutes. Client's son sits at the bedside while the nurse
assesses his father. Which assessment findings warrant immediate intervention by the nurse?
(Select all that apply. One, some or all options may be correct.) - Answer: - Client's Glasgow
Coma Scale (GCS) score changes from 12 to 9.
Rationale: A decreasing of the GCS indicates worsening of the client's condition. This finding
warrants immediate nursing intervention.
- Client has a positive Babinksi's reflex bilaterally.
Rationale: A negative Babinski's reflex is expected in a client with an intact brain stem. This
finding warrants immediate intervention by the nurse.
- Client is unable to verbalize responses to the nurse's questions.
Rationale: This assessment warrants intervention because client was previously able to
verbalize.
Due to his deteriorating condition, the neurologist is consulted to immediately see client. The
nurse suspects that client has probably suffered a right-sided stroke. Which clinical
manifestations further support this assessment? (Select all that apply. One, some or all options
may be correct.) - Answer: - Visual field deficit on the left side.
Rationale: The deficit occurs with right-sided stroke.
- Spatial-perceptual deficits.
Rationale: These deficits occur with right-sided stroke.
- Full or partial paralysis of the left sided hemiplegia.
Rationale: This deficit occurs with right-sided stroke.
- Increased distractibility and attention span.
Rationale: This deficit occurs with right-sided stroke.
The neurologist writes a diagnosis of "suspected stroke" and prescribes a computed
tomography (CT) scan without contrast STAT. Which intervention should the nurse implement
Medical Surgical Strokes
Comprehensive Questions
(Frequently Tested) with
Verified Answers Graded A+
Client, a 72-year-old male widower, lives with his son. Client tells his son that he has a headache
and that he is not feeling well. Son notices some left-sided weakness in his father and takes
client to the Emergency Department (ED). - Answer: The case study
The ED RN completes the full admission assessment and the assigned PN is present. Client 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 client's symptoms have been caused by a stroke? (Select all that apply. One, some, or all
options may be correct.) - Answer: - Hyperglycemia.
Rationale: Hyperglycemia (elevated blood sugar) may represent the body's stress response
during a stroke and has been shown to contribute to brain damage and more severe outcomes.
- Elevated blood pressure.
Rationale: When a client has a stroke, the blood pressure will often respond by increasing.
Increased blood pressure is also a sign of increased intracranial pressure and could signal
worsening of brain tissue damage.
- Arrhythmias.
Cardiac rhythms may become abnormal after a stroke. Continuous cardiac monitoring is
recommended to monitor ischemic heart changes and abnormal rhythms like atrial fibrillation.
, Following the ED healthcare provider's (HCP) assessment, the nurse continues to do focused
assessments on the client every 15 minutes. Client's son sits at the bedside while the nurse
assesses his father. Which assessment findings warrant immediate intervention by the nurse?
(Select all that apply. One, some or all options may be correct.) - Answer: - Client's Glasgow
Coma Scale (GCS) score changes from 12 to 9.
Rationale: A decreasing of the GCS indicates worsening of the client's condition. This finding
warrants immediate nursing intervention.
- Client has a positive Babinksi's reflex bilaterally.
Rationale: A negative Babinski's reflex is expected in a client with an intact brain stem. This
finding warrants immediate intervention by the nurse.
- Client is unable to verbalize responses to the nurse's questions.
Rationale: This assessment warrants intervention because client was previously able to
verbalize.
Due to his deteriorating condition, the neurologist is consulted to immediately see client. The
nurse suspects that client has probably suffered a right-sided stroke. Which clinical
manifestations further support this assessment? (Select all that apply. One, some or all options
may be correct.) - Answer: - Visual field deficit on the left side.
Rationale: The deficit occurs with right-sided stroke.
- Spatial-perceptual deficits.
Rationale: These deficits occur with right-sided stroke.
- Full or partial paralysis of the left sided hemiplegia.
Rationale: This deficit occurs with right-sided stroke.
- Increased distractibility and attention span.
Rationale: This deficit occurs with right-sided stroke.
The neurologist writes a diagnosis of "suspected stroke" and prescribes a computed
tomography (CT) scan without contrast STAT. Which intervention should the nurse implement
