Hesi Case Study Stroke questions and
answers 2025\2026 A+ Grade
The ED nurse completes the admission assessment. 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.)
- correct answer A. A carotid bruit.
B. A carotid bruit.
C. Hyporeflexic deep tendon reflexes.
Following the ED healthcare provider's (HCP) assessment, the nurse continues to assess client every 15
minutes. Client's son sits at the bedside while the nurse assess his father. Which assessment findings
warrant immediate intervention by the nurse? (Select all that apply. One, some or all options may be
correct.)
- 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.)
- correct answer A. Visual field deficit on the left side.
B. Spatial-perceptual deficits.
C. Paresthesia of the left side.
D. Increased distractibility.
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?
- correct answer B. Explain that the procedure requires the client to lie completely still.
, 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?
- correct answer C. Left hip replacement.
Which explanation by the nurse is the most therapeutic response?
- correct answer B. "Your father has had a stroke, and the blood supply to the brain has been
compromised."
The son 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?
- correct answer B. "I know this is scary for you. Would you like to sit and talk?"
The neurologist diagnoses an ischemic right-sided stroke. The neurologist determines that client is not a
candidate for tissue plasminogen activator (tPA). Enoxaparin sodium 1 mg/kg subcutaneously every 12
hours is ordered.
Client weighs 170 pounds. How many mg of enoxaparin sodium will the nurse administer in each dose?
- correct answer 77
With a diagnosis of a stroke, which priority interventions should the nurse include in client's plan of
care?
- correct answer A. Monitor PTT daily.
B. Assess neurological status every hour.
D. Keep the head of the bed elevated.
E. Monitor blood glucose levels daily.
The nurse continues to closely monitor client's condition. Which findings would require immediate
intervention by the nurse? (Select all that apply. One, some or all options may be correct.)
- correct answer B. Client's pulse oximeter reading has dropped to 90%.
C. Client's serum potassium level is 3.0 mEq/L (mmol/L).
E. Client's serum glucose is 150 (8.32 mmol/L).
Over the next 24 hour, client's 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
answers 2025\2026 A+ Grade
The ED nurse completes the admission assessment. 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.)
- correct answer A. A carotid bruit.
B. A carotid bruit.
C. Hyporeflexic deep tendon reflexes.
Following the ED healthcare provider's (HCP) assessment, the nurse continues to assess client every 15
minutes. Client's son sits at the bedside while the nurse assess his father. Which assessment findings
warrant immediate intervention by the nurse? (Select all that apply. One, some or all options may be
correct.)
- 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.)
- correct answer A. Visual field deficit on the left side.
B. Spatial-perceptual deficits.
C. Paresthesia of the left side.
D. Increased distractibility.
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?
- correct answer B. Explain that the procedure requires the client to lie completely still.
, 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?
- correct answer C. Left hip replacement.
Which explanation by the nurse is the most therapeutic response?
- correct answer B. "Your father has had a stroke, and the blood supply to the brain has been
compromised."
The son 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?
- correct answer B. "I know this is scary for you. Would you like to sit and talk?"
The neurologist diagnoses an ischemic right-sided stroke. The neurologist determines that client is not a
candidate for tissue plasminogen activator (tPA). Enoxaparin sodium 1 mg/kg subcutaneously every 12
hours is ordered.
Client weighs 170 pounds. How many mg of enoxaparin sodium will the nurse administer in each dose?
- correct answer 77
With a diagnosis of a stroke, which priority interventions should the nurse include in client's plan of
care?
- correct answer A. Monitor PTT daily.
B. Assess neurological status every hour.
D. Keep the head of the bed elevated.
E. Monitor blood glucose levels daily.
The nurse continues to closely monitor client's condition. Which findings would require immediate
intervention by the nurse? (Select all that apply. One, some or all options may be correct.)
- correct answer B. Client's pulse oximeter reading has dropped to 90%.
C. Client's serum potassium level is 3.0 mEq/L (mmol/L).
E. Client's serum glucose is 150 (8.32 mmol/L).
Over the next 24 hour, client's 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
