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Patient Data

Exhibits

For each focused assessment area, click to specify which findings indicate early interventions for an ischemic stroke were effective.

Each focused assessment area may support more than one clinical finding. Each category must have at least one response option selected.

Focused Assessment Area

Clinical Finding

Musculoskeletal

Ambulates with a walker

Flaccidity of left arm

Passive range of motion of the left leg

Psychosocial

Fits of laughter

Angry outbursts

Tearful sharing of stories

Neurological

Drinks with repetitive cough

Decorticate posturing

Speaks in short sentences

Ambulates with a walker

Flaccidity of left arm

Passive range of motion of the left leg

Fits of laughter

Angry outbursts

Tearful sharing of stories

Drinks with repetitive cough

Decorticate posturing

Speaks in short sentences

Answer and Explanation

The Correct Answer is ["A","F","I"]

Rationale:

Ambulates with a walker: Being able to walk, even with assistance, indicates improved muscle control and coordination on the affected side. This shows progress in motor recovery and suggests that blood flow has been restored to motor areas of the brain.
Tearful sharing of stories: Expressing emotion and recalling events indicate intact cognitive and communicative function. While post-stroke emotional lability can occur, this behavior also shows higher cortical functioning, which supports improved cerebral perfusion after treatment.
Speaks in short sentences: The ability to form and express language suggests that expressive and receptive language centers in the brain are functioning. Improvement in speech following initial garbling indicates that early ischemic stroke interventions are showing clinical benefits.

Rationale for Incorrect Choices:

Flaccidity of left arm: Persistent flaccidity implies ongoing neurological deficit and poor motor control on the affected side. This finding suggests that motor recovery has not yet occurred and may indicate continued brain tissue injury.
Passive range of motion of the left leg: Requiring passive movement assistance reflects impaired voluntary motor control. This does not support improved function or stroke recovery, as it indicates dependence rather than restored movement.
Fits of laughter: Sudden, inappropriate emotional expressions can signify pseudobulbar affect, a post-stroke complication. While common, it reflects disrupted emotional regulation rather than clinical improvement.
Angry outbursts: Emotional instability, including irritability and anger, may result from frontal lobe injury. It reflects emotional dysregulation, which can be a lingering or worsening effect of neurological damage, not an indicator of recovery.
Drinks with repetitive cough: Coughing when drinking signals impaired swallowing reflex and a risk for aspiration. This suggests that brain areas controlling swallowing are still affected, showing unresolved neurological deficits.
Decorticate posturing: This is a sign of severe brain injury and poor prognosis. It indicates worsening intracranial damage, not a positive response to ischemic stroke treatment.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

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

Explanation

Rationale:

A. Separate fluids from meals: Fluids should be consumed at least 30 minutes before or after meals to prevent gastric overdistention and dumping syndrome, which are common after bariatric surgery.

B. Plan meals to include rice porridge: Rice porridge is high in simple carbohydrates, which can cause dumping syndrome and rapid gastric emptying. It is not ideal post-surgery.

C. Eliminate acidic food choices: Acidic foods like citrus or tomatoes may cause discomfort, but they are not universally contraindicated. Tolerance varies by individual, so elimination is not routinely necessary.

D. Offer more bread and cheese: Bread can form a sticky bolus that’s hard to swallow post-op, and cheese is high in fat. Both can cause discomfort or intolerance early in recovery.

E. Provide small frequent meals: After bariatric surgery, the stomach’s capacity is reduced, so clients need to eat small, frequent meals to meet nutritional needs and prevent nausea or vomiting.

A. Confirm that the desired effect of the medication has been achieved. B. Explain that it may take several weeks for the medication to be effective. C. Evaluate when and how the medication is being administered to the client. D. Notify the healthcare provider that a change in dosage may be needed.

Correct Answer is A

Explanation

Rationale:

A. Confirm that the desired effect of the medication has been achieved: Trazodone is prescribed to improve mood and aid sleep, not to enhance cognitive function. Since the caregiver reports improvement in those areas, the medication is achieving its intended therapeutic outcomes.

B. Explain that it may take several weeks for the medication to be effective: While some antidepressants require time to reach full effectiveness, the caregiver already reports improved mood and sleep. There is no indication of delayed onset.

C. Evaluate when and how the medication is being administered to the client: No signs of improper administration or ineffective dosing are indicated. The caregiver's feedback suggests the medication is being given correctly and is having a beneficial effect.

D. Notify the healthcare provider that a change in dosage may be needed: Cognitive decline in Alzheimer's disease is progressive and not expected to improve with trazodone, so no dosage change is warranted based on this feedback.

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Body system	Findings
Cardiovascular	Blood pressure of 120/74 mm Hg Capillary refill of 4 seconds in lower extremities Pedal pulse of 2+ or better
Neurovascular	Pupils equal and nonresponsive to light Absence of numbness or tingling in feet Skin that is pale, cool to touch
Renal Perfusion	Client has urine output of 1,600 mL in 24 hours Creatinine of 1.2 mg/dL (106 mmol/L)

Focused Assessment Area	Clinical Finding
Musculoskeletal	Ambulates with a walker Flaccidity of left arm Passive range of motion of the left leg
Psychosocial	Fits of laughter Angry outbursts Tearful sharing of stories
Neurological	Drinks with repetitive cough Decorticate posturing Speaks in short sentences

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which dietary intervention(s) should the nurse include in the plan of care for a client who had bariatric surgery? Select all that apply.

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

Explanation

Correct Answer is A

Explanation

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Which information is most important for the nurse to obtain when determining a client's risk for obstructive sleep apnea syndrome (OSAS)?

The camp nurse is teaching adolescents about the prevention of tinea pedis. Which instruction should the nurse include in the teaching plan?

An adolescent with autism spectrum disorder (ASD) comes to the clinic for the first time. Which intervention(s) should the nurse implement? Select all that apply.