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 ["100"]

Explanation

To answer this question, we need to find the rate of infusion in milliliters per hour (mL/hr) that will deliver 1 liter (1000 mL) of 0.9% sodium chloride, USP intravenously (IV) over 10 hours. We can use the following formula to calculate the rate:

Rate(mL/hr)=Volume(mL)/Time(hr)

Plugging in the given values, we get:

Rate(mL/hr)=1000mL/10hr

Simplifying, we get:

Rate= 100mL/hr

A. Abdominal obesity. B. Blood pressure of 150/96 mm Hg. C. Elevated high density lipoproteins. D. Increased triglyceride levels. E. Hyperglycemia. F. Hypothyroidism.

Correct Answer is ["A","B","D","E"]

Explanation

Choice A reason: This is correct because abdominal obesity, also known as central obesity or visceral fat, is one of the criteria for diagnosing metabolic syndrome and a major risk factor for diabetes mellitus and vascular disease. Abdominal obesity is defined as having a waist circumference of more than 40 inches (102 cm) for men or 35 inches (88 cm) for women. Abdominal obesity can increase insulin resistance, inflammation, and blood pressure, which can lead to impaired glucose metabolism and cardiovascular complications.

Choice B reason: This is correct because blood pressure of 150/96 mm Hg is another criterion for diagnosing metabolic syndrome and a significant risk factor for diabetes mellitus and vascular disease. Blood pressure is defined as the force exerted by blood against the walls of blood vessels. Normal blood pressure is less than 120/80 mm Hg, while high blood pressure (hypertension) is 140/90 mm Hg or higher. High blood pressure can damage the blood vessels and organs, such as the heart, kidneys, eyes, and brain, and increase the risk of heart attack, stroke, kidney failure, and vision loss.

Choice C reason: This is incorrect because elevated high density lipoproteins (HDL), also known as good cholesterol, are not a criterion for diagnosing metabolic syndrome or a risk factor for diabetes mellitus and vascular disease. In fact, HDL are beneficial for cardiovascular health because they help remove excess cholesterol from the blood and prevent plaque buildup in the arteries. Normal HDL levels are 40 mg/dL (1.0 mmol/L) or higher for men and 50 mg/dL (1.3 mmol/L) or higher for women.

Choice D reason: This is correct because increased triglyceride levels are another criterion for diagnosing metabolic syndrome and a risk factor for diabetes mellitus and vascular disease. Triglycerides are a type of fat that circulates in the blood and provides energy to cells. Normal triglyceride levels are less than 150 mg/dL (1.7 mmol/L), while high triglyceride levels are 200 mg/dL (2.3 mmol/L) or higher. High triglyceride levels can increase insulin resistance, inflammation, and blood clotting, which can impair glucose metabolism and increase the risk of heart attack and stroke.

Choice E reason: This is correct because hyperglycemia, also known as high blood sugar, is another criterion for diagnosing metabolic syndrome and a hallmark of diabetes mellitus. Hyperglycemia occurs when the body cannot produce enough insulin or use it properly to regulate the amount of glucose in the blood. Normal blood glucose levels are 70 to 99 mg/dL (3.9 to 5.5 mmol/L) before meals and less than 140 mg/dL (7.8 mmol/L) two hours after meals, while hyperglycemia is 126 mg/dL (7.0 mmol/L) or higher before meals or 200 mg/dL (11.1 mmol/L) or higher two hours after meals. Hyperglycemia can damage the blood vessels and organs, such as the eyes, kidneys, nerves, and feet, and increase the risk of infections, ulcers, amputations, and diabetic ketoacidosis.

Choice F reason: This is incorrect because hypothyroidism, also known as underactive thyroid, is not a criterion for diagnosing metabolic syndrome or a direct risk factor for diabetes mellitus and vascular disease. Hypothyroidism occurs when the thyroid gland does not produce enough thyroid hormones, which regulate the body's metabolism, growth, and development. Hypothyroidism can cause symptoms such as fatigue, weight gain, cold intolerance, dry skin, hair loss, constipation, and depression. However, hypothyroidism does not affect the blood glucose or lipid levels directly, but rather indirectly through its effects on weight and appetite.

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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

The healthcare provider prescribes 1 liter of 0.9% sodium chloride, USP intravenously (IV) to be infused over 10 hours for a client. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)

Correct Answer is ["100"]

Explanation

The nurse prepares a teaching plan for an adult client with metabolic syndrome. Which finding(s) should the nurse address to help the client reduce the risk for diabetes mellitus and vascular disease? (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

Exhibits The triage nurse does a rapid assessment of the client. Which data indicates the client is in need of immediate health interventions?

A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA), which information should the nurse include in the discharge instructions?

The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?

After teaching a client newly diagnosed with cholecystitis about recommended diet changes, the nurse evaluates the client's learning. Which food choices eliminated by the client indicate to the nurse that teaching has been successful?

Exhibits For each assessment finding, explain whether the actions taken were effective or ineffective.

A patient is admitted to the hospital with symptoms consistent with a right hemisphere stroke. Which neurovascular assessment requires immediate intervention by the nurse?

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.