Case Study

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Answer Key #1 The emergency room nurse is completing the admission assessment. Nancy is alert, but struggles to answer questions. When she attempts to talk, she slurs her speech and appears very frightened. What additional clinical manifestation does the nurse expect to find if her symptoms were caused by a stroke? A -- A carotid bruit #2 Due to Nancy's deteriorating condition she is referred to a neurologist. The emergency room nurse realizes that she has probably suffered from a left-sided brain attack. What clinical manifestation further supports this assessment? D -- Global Aphasia #3 What nursing intervention should the nurse implement when preparing Nancy for a noncontrast CT scan? B -- Explain that the client will not be able to move her head thoughout the CT scan #4 The neurologist also prescribes a magnetic resonance imaging (MRI) of the head STAT, why? C -- Right hip replacement #5 Nancy's daughter Gail, starts to cry and states, 'Mom was fine last week when we went out to eat and to a show. I love my mom so much, and I am so scared. She is all I have.' How should the nurse respond B -- 'I know this is scary for you. Would you like to sit and talk?' #6 The neurologist diagnoses an ischemic left-sided brain attack (stroke). The neurologist determines that Nancy is not a candidate for tPA. Lovenox is prescribed. 1 mg/kg subQ every 12 hours. What intervention should the nurse include in the plan of care? D -- Keep the head of the bed elevated #7 The nurse in monitoring Nancy's condition closely. Which finding would require immediate intervention by the nurse? A -- Nancy's cardiac output is less than 4L/min #8 Nancy's cardiac output, SaO2, potassium level, and telemetry readings are within normal limits for her age. As the nurse assesses Nancy, Gail asks, 'Why isn't my mother a candidate for thrombolytic therapy?' The nurse's response should

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