Stroke Case Study

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Meet the Patient: Nancy Jackson, a 72-year-old Caucasian female, is brought to the Emergency Department at St. John's Medical Center, a Catholic facility, by her daughter, Gail. Mrs. Jackson, who asks the staff to call her Nancy, is complaining of right-sided weakness, a severe headache, and just not feeling well for the last 24 Hours. 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. B) Elevated blood pressure. C) Hyperreflexic deep tendon reflexes. D) Decreased bowel sounds. E) Difficulty swallowing. 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. B) Nancy’s bilateral grip strength is unequal. C) Nancy only responds to painful stimuli. D) Nancy has a negative Babinski's reflex bilaterally. 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. 3. Which clinical manifestation further supports this assessment? A) Visual field deficit on the left side. B) Spatial-perceptual deficits. C) Paresthesia of the left side. D) Global aphasia. Diagnostic Tests The neurologist writes a diagnosis of, "Suspected brain attack" and prescribes a noncontrast computed tomography (CT) scan STAT. 4. Which nursing intervention should the nurse implement when preparing Nancy and her daughter for this

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