Brain Attack Evolve Case Study
Points Awarded
31.00
Points Missed
0.00
Percentage
100%
Clinical Manifestations
The Emergency Department (ED) 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.
1.
Which additional clinical manifestation(s) should the nurse expect to find if Nancy's symptoms have been caused by a brain attack (stroke)? (Select all that apply.)
A) A carotid bruit.
CORRECT
The carotid artery (artery to the brain) is narrowed in clients with a brain attack (stroke). A bruit is an abnormal sound heard on auscultation resulting from interference with normal blood flow.
B) Elevated blood pressure.
CORRECT
When a client has a brain attack (stroke), the blood pressure will often respond by going up. Increased BP is a sign of increased intracranial pressure.
C) Hyperreflexic deep tendon reflexes.
INCORRECT
Initially, flaccid paralysis occurs, resulting in hyporeflexic deep tendon reflexes.
D) Decreased bowel sounds.
INCORRECT
The bowel sounds are not indicative of a brain attack.
E) Difficulty swallowing.
CORRECT
Difficulty swallowing can accompany a brain attack (stroke), placing the client at risk for aspiration.
The ED physician has completed an assessment. Gail is sitting at the bedside while the ED nurse continues to assess Nancy every 15 minutes.
2.
Which assessment finding warrants immediate intervention by the nurse?
A) Nancy’s Glasgow Coma Scale (GCS) score increases.
INCORRECT
A decreasing, not increasing, GCS indicates worsening of the client's condition. This finding does not warrant immediate intervention by the nurse.
B) Nancy’s bilateral grip strength is unequal.
INCORRECT
This is an expected finding in a client with a brain attack. This finding does not warrant immediate intervention by the nurse.
C) Nancy only responds to painful stimuli.
CORRECT
This decrease in
31.00
Points Missed
0.00
Percentage
100%
Clinical Manifestations
The Emergency Department (ED) 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.
1.
Which additional clinical manifestation(s) should the nurse expect to find if Nancy's symptoms have been caused by a brain attack (stroke)? (Select all that apply.)
A) A carotid bruit.
CORRECT
The carotid artery (artery to the brain) is narrowed in clients with a brain attack (stroke). A bruit is an abnormal sound heard on auscultation resulting from interference with normal blood flow.
B) Elevated blood pressure.
CORRECT
When a client has a brain attack (stroke), the blood pressure will often respond by going up. Increased BP is a sign of increased intracranial pressure.
C) Hyperreflexic deep tendon reflexes.
INCORRECT
Initially, flaccid paralysis occurs, resulting in hyporeflexic deep tendon reflexes.
D) Decreased bowel sounds.
INCORRECT
The bowel sounds are not indicative of a brain attack.
E) Difficulty swallowing.
CORRECT
Difficulty swallowing can accompany a brain attack (stroke), placing the client at risk for aspiration.
The ED physician has completed an assessment. Gail is sitting at the bedside while the ED nurse continues to assess Nancy every 15 minutes.
2.
Which assessment finding warrants immediate intervention by the nurse?
A) Nancy’s Glasgow Coma Scale (GCS) score increases.
INCORRECT
A decreasing, not increasing, GCS indicates worsening of the client's condition. This finding does not warrant immediate intervention by the nurse.
B) Nancy’s bilateral grip strength is unequal.
INCORRECT
This is an expected finding in a client with a brain attack. This finding does not warrant immediate intervention by the nurse.
C) Nancy only responds to painful stimuli.
CORRECT
This decrease in