Stroke HESI Case StudyMr. Hubert
Jones, a 72-year-old African American
male widower, lives with his son, Barry
Jones. Mr. Jones tells his son that he
has a headache and that he is not
feeling well. Barry notices some left-
sided weakness in his father and
The Emergency Department (ED) nurse completes the admission assessment. Mr.
Jones is alert but struggles to answer questions. When he attempts to talk, he slurs his
speech and appears very frightened. Which additional clinical manifestations should the
nurse expect to find if Mr. Jones' symptoms have been caused by a stroke?
Answer - carotid bruit
elevated BP
hyporeflexic DTR
Following the ED healthcare provider's (HCP) assessment, the ED nurse continues to
assess Mr. Jones every 15 minutes. Mr. Jones' son, Barry sits at the bedside while the
nurse assess Mr. Jones. Which assessment findings warrant immediate intervention by
the nurse?Answer - GCS changes from 12 to 9
positive Babinski's reflex bilaterally
unable to verbalize response to questions
Due to his deteriorating condition, the neurologist is consulted to see Mr. Jones
immediately. The nurse suspects that Mr. Jones has probably suffered a right-sided
stroke. Which clinical manifestations further support this assessment?
Answer - increased distractibility
visual deficit on left side
spatial-perceptual deficits
paresthesia on left side
(global aphasia L hemi)
The neurologist writes a diagnosis of "suspected stroke" and prescribes a computed
tomography (CT) scan without contrast STAT. Which intervention should the nurse
implement when preparing Mr. Jones and his son for this procedure?
Answer - Explain procedure requires client to lie completely still
, (head motion will distort the images, if his LOC is decreased he may require a head
support to accomplish this)
The neurologist also prescribes a magnetic resonance imaging (MRI) of the head STAT.
Which data warrants immediate intervention by the nurse concerning this diagnostic
test?
Answer - left hip replacement
Over the next 24 hour, Mr. Jones' SaO2, potassium level, and telemetry readings are
within normal limits for his age, but his cardiac output decreases. The HCP needs to be
notified regarding decreased cardiac output to decide whether to initiate IV fluid if
hypovolemia is an issue and to determine other medical interventions.Which nursing
interventions would be priority at this time?
Answer - monitor pulse ox, capillary refill, intake and output, and LOC
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."
Barry is visibly upset and states, "Dad has been fine all week. We even went out to
dinner. I love him so much and I am scared." How should the nurse respond?
Answer - "I know this is scary for you. Would you like to sit and talk?"
Which nursing care task should the nurse delegate to the UAP? (Select all the apply.)
Answer - measure I&Os
change linen and give bed bath
take vital signs
With a diagnosis of a stroke, which priority intervention should the nurse include in Mr.
Jones' plan of care?
Answer - monitor glucose daily
elevate head of bed
assess neuro status daily
monitor PTT daily
The HCP orders 360 mL of liquid nourishment diluted with one can of water to be
infused over 8 hours. The feeding will be administered through an infusion pump, which
infuses in mL/hr. At what rate would the nurse set the infusion pump? (Enter numerical
value only. If rounding is necessary, round to the whole number.)
Answer - 360 ml + 240 ml (8 oz x 30 ml)= 600 ml/8 hrs= 75 ml/hr
What actions should the nurse implement?Answer - Explain that Mr. Jones can only be
a tissue donor, not an organ donor
Obtain necessary permits and notify the organ donor center
The neurologist diagnoses an ischemic right-sided stroke. The neurologist determines
that Mr. Jones is not a candidate for tissue plasminogen activator (tPA). Enoxaparin 1
Jones, a 72-year-old African American
male widower, lives with his son, Barry
Jones. Mr. Jones tells his son that he
has a headache and that he is not
feeling well. Barry notices some left-
sided weakness in his father and
The Emergency Department (ED) nurse completes the admission assessment. Mr.
Jones is alert but struggles to answer questions. When he attempts to talk, he slurs his
speech and appears very frightened. Which additional clinical manifestations should the
nurse expect to find if Mr. Jones' symptoms have been caused by a stroke?
Answer - carotid bruit
elevated BP
hyporeflexic DTR
Following the ED healthcare provider's (HCP) assessment, the ED nurse continues to
assess Mr. Jones every 15 minutes. Mr. Jones' son, Barry sits at the bedside while the
nurse assess Mr. Jones. Which assessment findings warrant immediate intervention by
the nurse?Answer - GCS changes from 12 to 9
positive Babinski's reflex bilaterally
unable to verbalize response to questions
Due to his deteriorating condition, the neurologist is consulted to see Mr. Jones
immediately. The nurse suspects that Mr. Jones has probably suffered a right-sided
stroke. Which clinical manifestations further support this assessment?
Answer - increased distractibility
visual deficit on left side
spatial-perceptual deficits
paresthesia on left side
(global aphasia L hemi)
The neurologist writes a diagnosis of "suspected stroke" and prescribes a computed
tomography (CT) scan without contrast STAT. Which intervention should the nurse
implement when preparing Mr. Jones and his son for this procedure?
Answer - Explain procedure requires client to lie completely still
, (head motion will distort the images, if his LOC is decreased he may require a head
support to accomplish this)
The neurologist also prescribes a magnetic resonance imaging (MRI) of the head STAT.
Which data warrants immediate intervention by the nurse concerning this diagnostic
test?
Answer - left hip replacement
Over the next 24 hour, Mr. Jones' SaO2, potassium level, and telemetry readings are
within normal limits for his age, but his cardiac output decreases. The HCP needs to be
notified regarding decreased cardiac output to decide whether to initiate IV fluid if
hypovolemia is an issue and to determine other medical interventions.Which nursing
interventions would be priority at this time?
Answer - monitor pulse ox, capillary refill, intake and output, and LOC
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."
Barry is visibly upset and states, "Dad has been fine all week. We even went out to
dinner. I love him so much and I am scared." How should the nurse respond?
Answer - "I know this is scary for you. Would you like to sit and talk?"
Which nursing care task should the nurse delegate to the UAP? (Select all the apply.)
Answer - measure I&Os
change linen and give bed bath
take vital signs
With a diagnosis of a stroke, which priority intervention should the nurse include in Mr.
Jones' plan of care?
Answer - monitor glucose daily
elevate head of bed
assess neuro status daily
monitor PTT daily
The HCP orders 360 mL of liquid nourishment diluted with one can of water to be
infused over 8 hours. The feeding will be administered through an infusion pump, which
infuses in mL/hr. At what rate would the nurse set the infusion pump? (Enter numerical
value only. If rounding is necessary, round to the whole number.)
Answer - 360 ml + 240 ml (8 oz x 30 ml)= 600 ml/8 hrs= 75 ml/hr
What actions should the nurse implement?Answer - Explain that Mr. Jones can only be
a tissue donor, not an organ donor
Obtain necessary permits and notify the organ donor center
The neurologist diagnoses an ischemic right-sided stroke. The neurologist determines
that Mr. Jones is not a candidate for tissue plasminogen activator (tPA). Enoxaparin 1
