NURSING CARE OF THE CHILDBEARING FAMILY NUR 1234
– RASMUSSEN UNIVERSITY – 2024 – VSIM RUSSELL
SCENARIO QUESTIONS AND ANSWERS WITH COMPLETE
SOLUTIONS
The nurse is caring for four medical-surgical patients. Which patient should be assessed
using the Glasgow Coma Scale? - correct answer -A 47-year-old patient who suffered a
brain injury and lost consciousness in a motor vehicle accident.
The correct answer is a 47-year-old patient who suffered a brain injury and lost
consciousness in a motor vehicle accident. The Glasgow Coma Scale measures Eye
Opening, Verbal Response, and Motor Response and is typically used with patients
who have suffered a brain injury as a result of trauma. The 32-year-old patient who is
paraplegic was hospitalized for pneumonia, not a brain injury. The patient with cancer
who has anxiety and depression nor the older adult patient with dementia did not
experience a brain injury.
The nurse has an order to complete neurochecks every four hours. Which assessments
would the nurse include in the neurological examination? (Select all that apply.) -
correct answer -Level of consciousness, Memory, Sensory perception, Cranial nerves
Components of a neurological examination include memory, level of consciousness,
sensory perception, cranial nerves, patterns of speech, and bilateral hand grips. Range
of motion would be appropriate for a musculoskeletal assessment.
When taking a patient's health history, which of the following does the nurse identify as
risk factors for having a stroke? (Select all that apply.) - correct answer -Smoking,
Hypertension, Diabetes Mellitus
, Risk factors for stroke include hypertension, smoking, and diabetes. Obesity, not weight
loss, is a risk factor for stroke. Asthma is not a risk factor for stroke.
A patient with dysphagia following a stroke expresses concern about having difficulty
eating and drinking. What is the appropriate reply by the nurse? - correct answer -
Muscle weakness frequently occurs after a stroke; we need to make sure that food is not
going into your lungs.
The appropriate reply by the nurse would be to explain that muscle weakness
frequently occurs after a stroke. Making sure the GI tract is functioning would be an
appropriate action to take after surgery. Telling the patient to ask the provider is
inappropriate because the nurse is able to answer this question. Although the patient
may seem worried, the question is specifically about patient teaching rather than
therapeutic communication. The appropriate reply by the nurse would be to answer the
patient's question.
A patient is experiencing dysphagia following a stroke. How should the nurse position
the patient when administering medications? - correct answer -High Fowler's
The nurse should position the patient at 90 degrees (high Fowler's) or should sit the
patient upright in a chair. The nurse should not position the patient supine (on back),
semi-Fowler's (45 degrees), or left lateral (on the side) during medication
administration, because these positions can impede swallowing and the passage of
food/liquids into the stomach.
Which observation supports the possibility that a patient who has experienced a stroke
has aspirated? (Select all that apply.) - correct answer -Coughing, Regurgitation into the
mouth, Hoarseness
When a stroke patient begins coughing, demonstrates hoarseness, or regurgitates after
swallowing, the nurse should evaluate the possibility of aspiration. Vomiting and
nausea are not associated with aspiration.
– RASMUSSEN UNIVERSITY – 2024 – VSIM RUSSELL
SCENARIO QUESTIONS AND ANSWERS WITH COMPLETE
SOLUTIONS
The nurse is caring for four medical-surgical patients. Which patient should be assessed
using the Glasgow Coma Scale? - correct answer -A 47-year-old patient who suffered a
brain injury and lost consciousness in a motor vehicle accident.
The correct answer is a 47-year-old patient who suffered a brain injury and lost
consciousness in a motor vehicle accident. The Glasgow Coma Scale measures Eye
Opening, Verbal Response, and Motor Response and is typically used with patients
who have suffered a brain injury as a result of trauma. The 32-year-old patient who is
paraplegic was hospitalized for pneumonia, not a brain injury. The patient with cancer
who has anxiety and depression nor the older adult patient with dementia did not
experience a brain injury.
The nurse has an order to complete neurochecks every four hours. Which assessments
would the nurse include in the neurological examination? (Select all that apply.) -
correct answer -Level of consciousness, Memory, Sensory perception, Cranial nerves
Components of a neurological examination include memory, level of consciousness,
sensory perception, cranial nerves, patterns of speech, and bilateral hand grips. Range
of motion would be appropriate for a musculoskeletal assessment.
When taking a patient's health history, which of the following does the nurse identify as
risk factors for having a stroke? (Select all that apply.) - correct answer -Smoking,
Hypertension, Diabetes Mellitus
, Risk factors for stroke include hypertension, smoking, and diabetes. Obesity, not weight
loss, is a risk factor for stroke. Asthma is not a risk factor for stroke.
A patient with dysphagia following a stroke expresses concern about having difficulty
eating and drinking. What is the appropriate reply by the nurse? - correct answer -
Muscle weakness frequently occurs after a stroke; we need to make sure that food is not
going into your lungs.
The appropriate reply by the nurse would be to explain that muscle weakness
frequently occurs after a stroke. Making sure the GI tract is functioning would be an
appropriate action to take after surgery. Telling the patient to ask the provider is
inappropriate because the nurse is able to answer this question. Although the patient
may seem worried, the question is specifically about patient teaching rather than
therapeutic communication. The appropriate reply by the nurse would be to answer the
patient's question.
A patient is experiencing dysphagia following a stroke. How should the nurse position
the patient when administering medications? - correct answer -High Fowler's
The nurse should position the patient at 90 degrees (high Fowler's) or should sit the
patient upright in a chair. The nurse should not position the patient supine (on back),
semi-Fowler's (45 degrees), or left lateral (on the side) during medication
administration, because these positions can impede swallowing and the passage of
food/liquids into the stomach.
Which observation supports the possibility that a patient who has experienced a stroke
has aspirated? (Select all that apply.) - correct answer -Coughing, Regurgitation into the
mouth, Hoarseness
When a stroke patient begins coughing, demonstrates hoarseness, or regurgitates after
swallowing, the nurse should evaluate the possibility of aspiration. Vomiting and
nausea are not associated with aspiration.
