vSim Fundamentals | Vernon Russell
(Stroke, Aspiration Risks, Final vSim)
Neuro Check - CORRECT ANSWER-a. LOC
b. Sensory perception
d. Memory
e. Cranial Nerves
The nurse is evaluating a patient's neurological status. What should the nurse include
when assessing a patient's level of awareness? - CORRECT ANSWER-When
assessing level of awareness, the nurse should assess Time (e.g., what is today's date?
what day of the week is it?; Place (e.g., Where are you now? What is the name of this
city?); and Person (e.g., What is your name? How old are you?). If the patient is
oriented to time, place, and person, the nurse would document that the patient is alert
and oriented x 3.
Which observation supports the possibility that a patient who has experienced a stroke
has aspirated? (Select all that apply) - CORRECT ANSWER-a) Coughing
c) Hoarseness
e) Regurgitation into the mouth
A patient has been admitted with a diagnosis of stroke, and the nurse has received
orders to hold warfarin until lab results are received. What lab results does the nurse
anticipate reviewing prior to administering this medication? - CORRECT ANSWER-
PT/INR
Mr. Russell experienced dysphagia and mild left-sided weakness following his stroke.
For which additional symptoms of stroke should the nurse assess? (select all that apply)
- CORRECT ANSWER-a. Urinary incontinence
b. Communication difficulties
d. Sensory deficits
The nurse is assessing a patient using the Glasgow Coma Scale. Which of the following
are components of that scale? (select all that apply) - CORRECT ANSWER-a. Motor
response
b. Eye opening
e. Verbal response
Mr. Russell has an order for vital signs and neurochecks every four hours. Which
assessment findings, if made by the nurse, would indicate potential neurologic
compromise? (select all that apply.) - CORRECT ANSWER-a. Unequal pupils
c. Decreasing level of consciousness
(Stroke, Aspiration Risks, Final vSim)
Neuro Check - CORRECT ANSWER-a. LOC
b. Sensory perception
d. Memory
e. Cranial Nerves
The nurse is evaluating a patient's neurological status. What should the nurse include
when assessing a patient's level of awareness? - CORRECT ANSWER-When
assessing level of awareness, the nurse should assess Time (e.g., what is today's date?
what day of the week is it?; Place (e.g., Where are you now? What is the name of this
city?); and Person (e.g., What is your name? How old are you?). If the patient is
oriented to time, place, and person, the nurse would document that the patient is alert
and oriented x 3.
Which observation supports the possibility that a patient who has experienced a stroke
has aspirated? (Select all that apply) - CORRECT ANSWER-a) Coughing
c) Hoarseness
e) Regurgitation into the mouth
A patient has been admitted with a diagnosis of stroke, and the nurse has received
orders to hold warfarin until lab results are received. What lab results does the nurse
anticipate reviewing prior to administering this medication? - CORRECT ANSWER-
PT/INR
Mr. Russell experienced dysphagia and mild left-sided weakness following his stroke.
For which additional symptoms of stroke should the nurse assess? (select all that apply)
- CORRECT ANSWER-a. Urinary incontinence
b. Communication difficulties
d. Sensory deficits
The nurse is assessing a patient using the Glasgow Coma Scale. Which of the following
are components of that scale? (select all that apply) - CORRECT ANSWER-a. Motor
response
b. Eye opening
e. Verbal response
Mr. Russell has an order for vital signs and neurochecks every four hours. Which
assessment findings, if made by the nurse, would indicate potential neurologic
compromise? (select all that apply.) - CORRECT ANSWER-a. Unequal pupils
c. Decreasing level of consciousness
