HESI Medical Surgical Study Set (A+ GUARANTEED)

An ER nurse is completing an assessment on a patient that is alert but struggles to answer questions. When she attempts to talk, she slurs her speech and appears very frightened. What additional clinical manifestation does the nurse expect to find if nacy's sysmptoms have been caused by a brain attack (stroke)? A. A carotid bruit B. A hypotensive blood pressure C. hyperreflexic deep tendon relexes. D. Decreased bowel sounds correct answers A) A carotid bruit. Rationale: the carotid artery (artery to the brain) is narrowed in clients with a brain attack. A bruit is an abnormal sound heard on auscultation resulting from interference with normal blood flow. Usually the blood pressure is hypertensive. Initially flaccid paralysis occurs, resulting in hyporefkexic deep tendon reflexes. Bowel sounds are not indicative of a brain attack. Which clinical manifestation further supports an assessment of a left-sided brain attack? A) Visual field deficit on the left side. B) Spatial-perceptual deficits. C) Paresthesia of the left side. D) Global aphasia. D) Global aphasia. correct answers D) Global aphasia. Rationale: Global aphasia refers to difficulty speaking, listening, and understanding, as well as difficulty reading and writing. Symptoms vary from person to person. Aphasia may occur secondary to any brain injury involving the left hemisphere. Visual field deficits, spatial-perceptual deficits, and paresthsia of the left side usually occur with right-sided brain attack. When preparing a patient for a noncontrast computed tomography (CT) scan STAT, what nursing intervention should the nurse implement? A) Determine if the client has any allergies to iodine B) Explain that the client will not be able to move her head throughout the CT scan. C) Premedicate the client to decrease pain prior to having the procedure. D) Provide an explanation of relaxation exercises prior to the procedure. correct answers B) Explain that the client will not be able to move her head throughout the CT scan. Rationale: Because head motion will distort the images, Nancy will have to remain still throughout the procedure. Allergies to iodine is important if contrast dye is being used for the CT scan. Premedicating the client to decrease pain prior to the procedure is unnecessary because CT scanning is a noninvasive and painless procedure. Providing an explanation of relaxation exercises prior to the procedure is a worthwhile intervention to decrease anxiety but is not of highest priority.