HESI Case study older adult with stroke

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1. what risk factors in the client's history - history of TIA 13. after the CT scan is - "Is Charles claustrophic or afraid of
predispose him to stroke - african american completed closed-in, small spaces?"
- male gender - "Does Charles have any metal
- obese and piercings or metal implants?"
hypertensive - "Did Charles serve in the military
and does he have a history of
2. based on charles' history what is most charles sometimes
shrapnel from a war injury?"
significant piece of info that warrants a forgets to take his
more thorough investigation by nurse antihypertensive 14. the RN, LPN, and - measure intake and output
med UAP - obtain vital signs
- assist with positioning
3. within ten minutes of being monitor blood
transported to the ED pressure 15. which medications if - heparin
listed to be given - aspirin
4. based on his presenting symptoms - slow, cautious
- antithrombotic
behavior and
- warfarin
anxiety
- slurred speech 16. which nursing ineffective airway clearance
and aphasia diagnosis
- inability to
17. in addition to administer mannitol (osmitrol) as
understand
elevating the head ordered
speech and simple
of the bed
math
18. what is the best high blood pressure is common after
5. which nursing observations - sudden onset
response for the a stroke. it is the body's way of
with progression
nurse assuring a sufficient blood flow to the
of symptoms over
brain
hours
- no loss of 19. after an infusion of cerebral hemorrhage
consciousness in rtpa
the first 24 hours 20. what is an accurate a very small catheter with a retriever
- history of TIA explanation will be inserted in the femoral artery.
- often occurs the retriever will enter the artery that
during or after is blocked and remove the clot.
sleep
21. which statement the scale evaluates impact of cerebral
6. based on charles weight (245 lbs), what 100.2 about the national infarction on comprehensive
is the total dose for the rtPA infusion? institutes of health neurological functioning
7. the pharmacy send an IVPB 167 stroke scale is
correct
8. charles is to receive 10% 51
22. the nurse prepares determine if the client can swallow a
9. the remainder of the rtpa 150
to give charles the small amount of crushed ice
10. client outcome are often related to remove dentures first feeding
and implement
23. charles receives International Normalization Ratio
seizure
enoxaparin (INR)
precautions
24. the nurse delegates the UAP measures the calf and thigh,
11. the nurse prioritizes airway prepare the client
care assignments to noting any swelling, warmth, or pain.
management for intubation
the UAP
12. charles is schedule to have an open CT - "Does Charles
25. the nurse positions apply high topped tennis shoes on
have a shellfish
charles in bed the client
(crustacean)
allergy?"
- "Does Charles
have an allergy to
iodine?"
26. the plan of care for the client to prevent skin breakdown - avoid massaging any areas of redness
- apply heel protectors on the client's heels
- place a pressure relieving mattress on the bed
27. the nurse plans interventions to promote bowel motility administer the prescribed stool softener daily
28. the nurse updates the plan of care for urinary apply an external catheter
management
29. charles has an intact gag reflex - encourage the client to make selections from his menu
- ask sheila for a list of charles' favorite healthy choice foods
- position the client upright in a chair for meals
30. the nurse wishes to determine if charles is ready the client corrects his own posture when sitting at the edge of the
bed