HESI RN EXIT CASE STUDY - STROKE
1. The Emergency Department (ED) nurse completes the admission
assess- ment. Mr. Jones is alert but struggles to answer questions. When
he attemptsto talk, he slurs his speech and appears very frightened.
Which additional clinical manifestations should the nurse expect to find if
Mr. Jones' symptomshave been caused by a stroke
Answer: carotid bruit
elevated BP
hyporeflexic
DTR
2. Which assessment finding warrants immediate intervention by the RN?
Answer: (Select all): Mr. Jones' Glasgow Coma Scale (GCS) score changes
from 12 to 9Mr. Jones has a positive Babinski's reflex bilaterally
Mr. Jones is unable to verbalize responses to the nurse's questions
3. Due to his deteriorating condition, the neurologist is consulted to see
Mr. Jones immediately.The nurse suspects that Mr. Jones has probably
suffered aright-sided stroke. Which clinical manifestations further
support this assess-ment
Answer: increased distractibility
visual deficit on left
1/4
, side spatial-perceptual
deficitsparesthesia on
left side
4. The neurologist writes a diagnosis of "suspected stroke" and prescribes
a
computed tomography (CT) scan without contrast STAT. Which
interventionshould the nurse implement when preparing Mr. Jones and
his son for thisprocedure
Answer: Explain procedure requires client to lie completely still
5. The neurologist also prescribes a magnetic resonance imaging (MRI)
ofthe head STAT. Which data warrants immediate intervention by the
nurse concerning this diagnostic test
Answer: left hip replacement
6. Which explanation by the nurse is the most therapeutic response
Answer: "Your father has had a stroke, and the blood supply to the brain has
been compromised."
7. Barry is visibly upset and states, "Dad has been fine all week. We even
wentout to dinner. I love him so much and I am scared." How should the
nurse respond
2/4
1. The Emergency Department (ED) nurse completes the admission
assess- ment. Mr. Jones is alert but struggles to answer questions. When
he attemptsto talk, he slurs his speech and appears very frightened.
Which additional clinical manifestations should the nurse expect to find if
Mr. Jones' symptomshave been caused by a stroke
Answer: carotid bruit
elevated BP
hyporeflexic
DTR
2. Which assessment finding warrants immediate intervention by the RN?
Answer: (Select all): Mr. Jones' Glasgow Coma Scale (GCS) score changes
from 12 to 9Mr. Jones has a positive Babinski's reflex bilaterally
Mr. Jones is unable to verbalize responses to the nurse's questions
3. Due to his deteriorating condition, the neurologist is consulted to see
Mr. Jones immediately.The nurse suspects that Mr. Jones has probably
suffered aright-sided stroke. Which clinical manifestations further
support this assess-ment
Answer: increased distractibility
visual deficit on left
1/4
, side spatial-perceptual
deficitsparesthesia on
left side
4. The neurologist writes a diagnosis of "suspected stroke" and prescribes
a
computed tomography (CT) scan without contrast STAT. Which
interventionshould the nurse implement when preparing Mr. Jones and
his son for thisprocedure
Answer: Explain procedure requires client to lie completely still
5. The neurologist also prescribes a magnetic resonance imaging (MRI)
ofthe head STAT. Which data warrants immediate intervention by the
nurse concerning this diagnostic test
Answer: left hip replacement
6. Which explanation by the nurse is the most therapeutic response
Answer: "Your father has had a stroke, and the blood supply to the brain has
been compromised."
7. Barry is visibly upset and states, "Dad has been fine all week. We even
wentout to dinner. I love him so much and I am scared." How should the
nurse respond
2/4
