Brain Attack Evolve Case Study

Topics: Nursing, Stroke, Traumatic brain injury Pages: 29 (5160 words) Published: September 19, 2014

Points Awarded
Points Missed

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.  

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.
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.
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.
Initially, flaccid paralysis occurs, resulting in hyporeflexic deep tendon reflexes.

D) Decreased bowel sounds.
The bowel sounds are not indicative of a brain attack.

E) Difficulty swallowing.
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.

Which assessment finding warrants immediate intervention by the nurse? A) Nancy’s Glasgow Coma Scale (GCS) score increases.
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.
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.
This decrease in responsiveness warrants immediate intervention by the nurse, indicating a worsening condition (increased intracranial pressure).

D) Nancy has a negative Babinski's reflex bilaterally.
A negative Babinski's reflex is expected in a client with an intact brain stem. This finding does not warrant immediate intervention by the nurse.

Due to her deteriorating condition, Nancy is immediately referred to the neurologist. The ED nurse realizes that Nancy has probably suffered a left-sided brain attack.

Which clinical manifestation further supports this assessment? A) Visual field deficit on the left side.
These deficits usually occur with right-sided brain attack.

B) Spatial-perceptual deficits.
These deficits usually occur with right-sided brain attack.

C) Paresthesia of the left side.
These deficits usually occur with right-sided brain attack.

D) Global aphasia.
Global aphasia refers to difficulty speaking, listening, and understanding, as well as difficulty reading and writing. Symptoms vary from person to person. Aphasia may occur secondary to any brain injury involving the left hemisphere.  

Diagnostic Tests
The neurologist writes a diagnosis of, "Suspected brain attack" and prescribes a noncontrast computed tomography (CT) scan STAT.

Which nursing intervention should the nurse implement when preparing Nancy and her daughter for this procedure? A) Determine if the client has any allergies to iodine.
This information is important if contrast dye is being used for the CT scan.

B) Explain to the daughter that her mother will have to remain still throughout the CT scan. CORRECT
Because head motion will distort the images, Nancy will have to remain still throughout the procedure. Since Nancy has a decreased LOC, she may require head support to accomplish this.

C) Premedicate the client to decrease pain prior to having the procedure. INCORRECT
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