NU371 HESI Case Study: Stroke
UPDATED Exam Questions and
CORRECT Answers
Meet the Client - Correct Answer- Client, a 72-year-old male widower, lives with his son.
Client tells his son that he has a headache and that he is not feeling well. Son notices some
left-sided weakness in his father and takes client to the Emergency Department (ED).
The ED RN completes the full admission assessment and the assigned PN is present. Client 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 client's symptoms have been caused by a stroke? (Select all that apply. One, some, or
all options may be correct.)
a) Hyperglycemia.
b) Elevated blood pressure.
c) Arrhythmias.
d) Amblyopia
e) Difference in temperature of upper and lower extremities. - Correct Answer- a)
Hyperglycemia.
b) Elevated blood pressure.
c) Arrhythmias.
-
Hyperglycemia (elevated blood sugar) may represent the body's stress response during a
stroke and has been shown to contribute to brain damage and more severe outcomes.When a
client has a stroke, the blood pressure will often respond by increasing. Increased blood
pressure is also a sign of increased intracranial pressure and could signal worsening of brain
tissue damage.Cardiac rhythms may become abnormal after a stroke. Continuous cardiac
monitoring is recommended to monitor ischemic heart changes and abnormal rhythms like
atrial fibrillation.
Following the ED healthcare provider's (HCP) assessment, the nurse continues to do focused
assessments on the client every 15 minutes. Client's son sits at the bedside while the nurse
assesses his father. Which assessment findings warrant immediate intervention by the nurse?
(Select all that apply. One, some or all options may be correct.)
a) Client's Glasgow Coma Scale (GCS) score changes from 12 to 9.
b) Client's motor strength is unequal.
, c) Client responds to painful stimuli.
d) Client has a positive Babinski's reflex bilaterally.
e) Client is unable to verbalize responses to the nurse's questions. - Correct Answer- a)
Client's Glasgow Coma Scale (GCS) score changes from 12 to 9.
d) Client has a positive Babinski's reflex bilaterally.
e) Client is unable to verbalize responses to the nurse's questions.
Due to his deteriorating condition, the neurologist is consulted to immediately see client. The
nurse suspects that client has probably suffered a right-sided stroke. Which clinical
manifestations further support this assessment? (Select all that apply. One, some or all
options may be correct.)
a) Visual field deficit on the left side.
b) Spatial-perceptual deficits.
c) Full or partial paralysis of the left side: hemiplegia.
d) Increased distractibility and attention span.
e) Global aphasia. - Correct Answer- a) Visual field deficit on the left side.
b) Spatial-perceptual deficits.
c) Full or partial paralysis of the left side: hemiplegia.
d) Increased distractibility and attention span.
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 client and his son for this procedure?
a) Determine if the client has any allergies to iodine or shellfish.
b) Explain that the procedure requires the client to lie completely still.
c) Offer client an anxiolytic prior to the procedure.
d) Ensure that client does not have on any material that is metal, this includes metal
prosthesis. - Correct Answer- b) Explain that the procedure requires the client to lie
completely still.
-
Because head motion will distort the images, client will have to remain still throughout the
procedure. Since client has a decreased level of consciousness (LOC), he may require head
support to accomplish this.
UPDATED Exam Questions and
CORRECT Answers
Meet the Client - Correct Answer- Client, a 72-year-old male widower, lives with his son.
Client tells his son that he has a headache and that he is not feeling well. Son notices some
left-sided weakness in his father and takes client to the Emergency Department (ED).
The ED RN completes the full admission assessment and the assigned PN is present. Client 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 client's symptoms have been caused by a stroke? (Select all that apply. One, some, or
all options may be correct.)
a) Hyperglycemia.
b) Elevated blood pressure.
c) Arrhythmias.
d) Amblyopia
e) Difference in temperature of upper and lower extremities. - Correct Answer- a)
Hyperglycemia.
b) Elevated blood pressure.
c) Arrhythmias.
-
Hyperglycemia (elevated blood sugar) may represent the body's stress response during a
stroke and has been shown to contribute to brain damage and more severe outcomes.When a
client has a stroke, the blood pressure will often respond by increasing. Increased blood
pressure is also a sign of increased intracranial pressure and could signal worsening of brain
tissue damage.Cardiac rhythms may become abnormal after a stroke. Continuous cardiac
monitoring is recommended to monitor ischemic heart changes and abnormal rhythms like
atrial fibrillation.
Following the ED healthcare provider's (HCP) assessment, the nurse continues to do focused
assessments on the client every 15 minutes. Client's son sits at the bedside while the nurse
assesses his father. Which assessment findings warrant immediate intervention by the nurse?
(Select all that apply. One, some or all options may be correct.)
a) Client's Glasgow Coma Scale (GCS) score changes from 12 to 9.
b) Client's motor strength is unequal.
, c) Client responds to painful stimuli.
d) Client has a positive Babinski's reflex bilaterally.
e) Client is unable to verbalize responses to the nurse's questions. - Correct Answer- a)
Client's Glasgow Coma Scale (GCS) score changes from 12 to 9.
d) Client has a positive Babinski's reflex bilaterally.
e) Client is unable to verbalize responses to the nurse's questions.
Due to his deteriorating condition, the neurologist is consulted to immediately see client. The
nurse suspects that client has probably suffered a right-sided stroke. Which clinical
manifestations further support this assessment? (Select all that apply. One, some or all
options may be correct.)
a) Visual field deficit on the left side.
b) Spatial-perceptual deficits.
c) Full or partial paralysis of the left side: hemiplegia.
d) Increased distractibility and attention span.
e) Global aphasia. - Correct Answer- a) Visual field deficit on the left side.
b) Spatial-perceptual deficits.
c) Full or partial paralysis of the left side: hemiplegia.
d) Increased distractibility and attention span.
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 client and his son for this procedure?
a) Determine if the client has any allergies to iodine or shellfish.
b) Explain that the procedure requires the client to lie completely still.
c) Offer client an anxiolytic prior to the procedure.
d) Ensure that client does not have on any material that is metal, this includes metal
prosthesis. - Correct Answer- b) Explain that the procedure requires the client to lie
completely still.
-
Because head motion will distort the images, client will have to remain still throughout the
procedure. Since client has a decreased level of consciousness (LOC), he may require head
support to accomplish this.
