Case Study Questions On Brain Attack

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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…show more content…
Non-modifiable risk factor means the client cannot do anything to change the risk factor. Gail tells the nurse she is going to go outside to smoke a cigarette and will only be gone for a few minutes. 16. Which statement is warranted in this situation? A) "I should let you know that smoking is a strong risk factor for a brain attack." CORRECT The nurse should teach Gail that smoking is a modifiable risk factor that could prevent her from having a stroke. Smoking increases the risk for hypertension, which is a risk factor for a stroke. B) "That is just fine. I will be here taking care of your mother." INCORRECT This response enables, and possibly encourages, Gail to continue smoking. C) "Make sure you smoke in the smoking area only. The hospital has strict rules." INCORRECT This response enables, and possibly encourages, Gail to continue smoking. D) "How long have you been smoking?" INCORRECT While this is useful information, it does not address Gail's decision to go out and smoke. Nursing Interventions Nancy is experiencing homonymous hemianopsia as the result of her brain…show more content…
Which action should the nurse implement? A) Notify the chaplain services immediately so the priest can come to the bedside. CORRECT The nurse must advocate for the client and family and should allow Nancy to have Last Rites. B) Explain since Nancy has already received Anointing of the Sick, there is no need to call a priest. INCORRECT The nurse must support the client's religious beliefs. C) Tell Nancy she must contact her own priest to come and bless Nancy. INCORRECT The nurse can support the client's wishes and religious beliefs by actively assisting her while she is grieving. D) Discuss how long Gail thinks it will take for a priest to come to the hospital. INCORRECT The nurse must support the client's religious beliefs and not worry about the length of time it would take to notify a priest. Gail is crying quietly while sitting in Nancy's room. Gail tells the nurse that her mother wanted to be cremated and to have her ashes thrown over the lake where Nancy and her husband met over 50 years ago. Gail wants to bury her mother beside her father in the local cemetery and tells the nurse, "I just don't know what I should do." 31. How should the nurse respond? A) "You should do what your mother
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