HESI MED STROKE

HESI MED STROKEThe ED nurse is completing the admission assessment. Nancy is alert but struggles to answer questions. When she attempts to talk, she slurs her speech and appears very frightened. Which additional clinical manifestations should the nurse expect to find if Nancy's symptoms have been caused by a brain attack (stroke)? A. Difficulty swallowing B. Decreased bowel sounds C. A carotid bruit D. Elevated blood pressure E. Hyperreflexic deep tendon reflexes A. Difficulty swallowing - Difficulty swallowing can accompany a brain attack, placing the client at risk for aspiration. C. A carotid bruit - The carotid artery (artery to the brain) is narrowed in clients with a brain attack (stroke). A bruit is an abnormal sound heard on auscultation resulting from interference with normal blood flow. D. Elevated blood pressure - When a client has a brain attack (stroke), the blood pressure will often respond by going up. Increased BP is a sign of increased intracranial pressure. The ED physician has completed an assessment. Gail is sitting at the bedside while the ED nurse continues to assess Nancy every 15 minutes. Which assessment finding warrants immediate intervention by the nurse? A. Nancy has a negative Babinski's reflex bilaterally B. Nancy only responds to a painful stimuli C. Nancy's Glasgow Coma Scale (GCS) score increases D. Nancy's bilateral grip strength is unequal B. Nancy only responds to painful stimuli - This decrease in responsiveness warrants immediate intervention by the nurse, indicating a worsening condition (increased intracranial pressure). Due to her deteriorating condition, Nancy is immediately referred to the neurologist. The ED nurse realizes that Nancy has probably suffered a left-sided brain attack. Which clinical manifestation further supports this assessment? A. Spatial-perceptual deficits. B. Visual field deficit on the left side C. Paresthesia of the left side D. Global aphasia D. Global aphasia -Global aphasia refers to difficulty speaking, listening, and writing. Symptoms vary from person to person. Aphasia may occur secondary to any brain injury involving the left hemisphere. The neurologist writes a diagnosis of "Suspected brain attack" and prescribes a non contrast computed tomography (CT) scan STAT. Which nursing intervention should the nurse implement when preparing