Patient Data

Exhibits

Specify which findings indicate early interventions for an ischemic stroke were effective? Each focused assessment area may support more than one clinical finding.

Answer and Explanation

The Correct Answer is []

Focused assesment area : Neurological

The correct answer is B. Speaks in short sentences.

Choice A: Drinks with repetitive cough. This is an incorrect answer because it indicates that the patient has difficulty swallowing, which is a common complication of ischemic stroke. Swallowing problems can lead to aspiration pneumonia, dehydration, and malnutrition. Therefore, this finding does not indicate effective early intervention for ischemic stroke¹.

Choice B: Speaks in short sentences. This is a correct answer because it indicates that the patient's speech has improved from being garbled to being intelligible. Speech impairment is a common symptom of ischemic stroke, especially when the left hemisphere of the brain is affected. Early intervention with thrombolytic therapy or mechanical thrombectomy can restore blood flow to the affected brain tissue and reduce the extent of damage². Therefore, this finding indicates effective early intervention for ischemic stroke.

Choice C: Decorticate posturing. This is an incorrect answer because it indicates that the patient has severe brain damage and is in a state of coma. Decorticate posturing is a type of abnormal posture that occurs when the upper limbs flex and the lower limbs extend in response to pain or stimulation. It indicates damage to the cerebral hemispheres or the internal capsule³. Therefore, this finding does not indicate effective early intervention for ischemic stroke.

Focused assesment area : Muscoskeletal

The correct answer is B. Ambulates with a walker.

Choice A: Flaccidity of left arm. This is an incorrect answer because it indicates that the patient has weakness or paralysis of the left arm, which is a common symptom of ischemic stroke. Flaccidity is the absence of muscle tone or resistance to passive movement. It indicates damage to the motor cortex or the corticospinal tract. Therefore, this finding does not indicate effective early intervention for ischemic stroke.

Choice B: Ambulates with a walker. This is a correct answer because it indicates that the patient has regained some mobility and independence after the ischemic stroke. Ambulation is the ability to walk or move from one place to another. Early intervention with physical therapy and rehabilitation can help improve the patient's functional recovery and prevent complications such as deep vein thrombosis, pressure ulcers, and contractures. Therefore, this finding indicates effective early intervention for ischemic stroke.

Choice C: Passive range of motion on left leg. This is an incorrect answer because it indicates that the patient has limited or no voluntary movement of the left leg, which is another common symptom of ischemic stroke. Passive range of motion is the movement of a joint or limb by an external force, such as a therapist or a caregiver. It indicates damage to the motor cortex or the corticospinal tract. Therefore, this finding does not indicate effective early intervention for ischemic stroke.

Focused assesment area : Psychosocial

The correct answer is B. Tearful sharing of stories.

Choice A: Fits of laughter. This is an incorrect answer because it indicates that the patient has inappropriate emotional responses, which is a common complication of ischemic stroke. Inappropriate emotional responses are sudden and uncontrollable episodes of laughing or crying that are out of context or disproportionate to the situation. They indicate damage to the brain regions that regulate emotions, such as the frontal lobe, the thalamus, or the brainstem. Therefore, this finding does not indicate effective early intervention for ischemic stroke.

Choice B: Tearful sharing of stories. This is a correct answer because it indicates that the patient has improved social and emotional functioning after the ischemic stroke. Tearful sharing of stories is a normal and healthy way of expressing emotions and coping with stress. It also shows that the patient has preserved memory and language skills, which are often impaired by ischemic stroke. Early intervention with psychological support and counseling can help the patient deal with the emotional impact of stroke and improve their quality of life. Therefore, this finding indicates effective early intervention for ischemic stroke.

Choice C: Angry outburst. This is an incorrect answer because it indicates that the patient has mood disturbances, which is another common complication of ischemic stroke. Mood disturbances are changes in the patient's emotional state, such as depression, anxiety, irritability, or aggression. They indicate damage to the brain regions that regulate mood, such as the frontal lobe, the amygdala, or the hippocampus. Therefore, this finding does not indicate effective early intervention for ischemic stroke.

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Correct Answer is ["F","H"]

Explanation

a) Basic metabolic panel: This is a blood test that measures the levels of electrolytes, glucose, calcium, and kidney function. It is not a priority order for this client because her glucose level is within the normal range and her symptoms are not indicative of electrolyte imbalance or kidney failure.

b) Echocardiogram: This is a test that uses sound waves to create images of the heart and its valves, chambers, and blood flow. It is not a priority order for this client because her chest discomfort may not be related to a cardiac problem and her SpO2 is normal, indicating adequate oxygenation.

c) CT scan of abdomen: This is a test that uses X-rays to create detailed pictures of the organs and structures in the abdomen. It is not a priority order for this client because her abdominal pain is not severe or acute and her nausea and poor appetite may be due to her illness or dialysis.

d) Blood cultures times 2 sets: This is a test that checks for the presence of bacteria or fungi in the blood. It is not a priority order for this client because she does not have signs of infection such as fever, chills, or leukocytosis.

e) Chest X-ray: This is a test that uses X-rays to create images of the lungs and chest wall. It is not a priority order for this client because she does not have respiratory symptoms such as cough, shortness of breath, or wheezes.

f) Place on continuous cardiac monitor: This is an order that requires the nurse to attach electrodes to the client's chest and monitor the heart rate and rhythm continuously. This is a priority order for this client because she has a history of CAD and HTN and reports chest discomfort and lightheadedness, which could indicate a possible myocardial infarction (heart attack) or arrhythmia (irregular heartbeat).

g) CBC: This is a blood test that measures the number and types of blood cells, such as red blood cells, white blood cells, and platelets. It is not a priority order for this client because she does not have signs of anemia, bleeding, or infection.

h) 12 lead EKG: This is a test that records the electrical activity of the heart from 12 different angles. It can detect abnormalities in the heart's rhythm, conduction, or damage. This is a priority order for this client because she has a history of CAD and HTN and reports chest discomfort and lightheadedness, which could indicate a possible myocardial infarction (heart attack) or arrhythmia (irregular heartbeat).

A. Sweet potatoes. B. Spinach salad. C. Bananas. D. Fish.

Correct Answer is B

Explanation

Choice A reason: Sweet potatoes are not a food that the client should avoid after passing a calcium oxalate renal stone, because they are low in oxalate, which is a substance that can combine with calcium in the urine and form stones. The client should limit foods that are high in oxalate, such as spinach, rhubarb, beets, nuts, chocolate, tea, and wheat bran. Therefore, this choice is incorrect.

Choice B reason: Spinach salad is a food that the client should avoid after passing a calcium oxalate renal stone, because it is high in oxalate, which can increase the risk of stone formation. The client should consume foods that are low in oxalate, such as rice, corn, apples, grapes, peaches, and cheese. Therefore, this choice is correct.

Choice C reason: Bananas are not a food that the client should avoid after passing a calcium oxalate renal stone, because they are low in oxalate and high in potassium, which can help prevent stone formation. The client should increase the intake of fluids, calcium, and citrate, which can reduce the concentration of oxalate and calcium in the urine and inhibit stone formation. Therefore, this choice is incorrect.

Choice D reason: Fish is not a food that the client should avoid after passing a calcium oxalate renal stone, because it is low in oxalate and high in protein, which can help maintain muscle mass and prevent weight loss. The client should moderate the intake of animal protein, such as meat, poultry, eggs, and dairy products, which can increase the acidity of the urine and promote stone formation. Therefore, this choice is incorrect.

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Patient Data Exhibits Specify which findings indicate early interventions for an ischemic stroke were effective? Each focused assessment area may support more than one clinical finding.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The nurse is reviewing the physician orders. Which of the following physician’s orders requires priority attention from the nurse? Select all that apply.

Correct Answer is ["F","H"]

Explanation

The nurse is providing dietary instructions for a client who is being discharged after passing a calcium oxalate renal stone. Which food should the nurse instruct the client to avoid?

Correct Answer is B

Explanation

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Patient Data

Exhibits

Specify which findings indicate early interventions for an ischemic stroke were effective? Each focused assessment area may support more than one clinical finding.