Patient Data
Specify which findings indicate early interventions for an ischemic stroke were effective? Each focused assessment area may support more than one clinical finding.
The Correct Answer is []
Focused assesment area : Neurological
The correct answer is B. Speaks in short sentences.
Choice A: Drinks with repetitive cough. This is an incorrect answer because it indicates that the patient has difficulty swallowing, which is a common complication of ischemic stroke. Swallowing problems can lead to aspiration pneumonia, dehydration, and malnutrition. Therefore, this finding does not indicate effective early intervention for ischemic stroke¹.
Choice B: Speaks in short sentences. This is a correct answer because it indicates that the patient's speech has improved from being garbled to being intelligible. Speech impairment is a common symptom of ischemic stroke, especially when the left hemisphere of the brain is affected. Early intervention with thrombolytic therapy or mechanical thrombectomy can restore blood flow to the affected brain tissue and reduce the extent of damage². Therefore, this finding indicates effective early intervention for ischemic stroke.
Choice C: Decorticate posturing. This is an incorrect answer because it indicates that the patient has severe brain damage and is in a state of coma. Decorticate posturing is a type of abnormal posture that occurs when the upper limbs flex and the lower limbs extend in response to pain or stimulation. It indicates damage to the cerebral hemispheres or the internal capsule³. Therefore, this finding does not indicate effective early intervention for ischemic stroke.
Focused assesment area : Muscoskeletal
The correct answer is B. Ambulates with a walker.
Choice A: Flaccidity of left arm. This is an incorrect answer because it indicates that the patient has weakness or paralysis of the left arm, which is a common symptom of ischemic stroke. Flaccidity is the absence of muscle tone or resistance to passive movement. It indicates damage to the motor cortex or the corticospinal tract. Therefore, this finding does not indicate effective early intervention for ischemic stroke.
Choice B: Ambulates with a walker. This is a correct answer because it indicates that the patient has regained some mobility and independence after the ischemic stroke. Ambulation is the ability to walk or move from one place to another. Early intervention with physical therapy and rehabilitation can help improve the patient's functional recovery and prevent complications such as deep vein thrombosis, pressure ulcers, and contractures. Therefore, this finding indicates effective early intervention for ischemic stroke.
Choice C: Passive range of motion on left leg. This is an incorrect answer because it indicates that the patient has limited or no voluntary movement of the left leg, which is another common symptom of ischemic stroke. Passive range of motion is the movement of a joint or limb by an external force, such as a therapist or a caregiver. It indicates damage to the motor cortex or the corticospinal tract. Therefore, this finding does not indicate effective early intervention for ischemic stroke.
Focused assesment area : Psychosocial
The correct answer is B. Tearful sharing of stories.
Choice A: Fits of laughter. This is an incorrect answer because it indicates that the patient has inappropriate emotional responses, which is a common complication of ischemic stroke. Inappropriate emotional responses are sudden and uncontrollable episodes of laughing or crying that are out of context or disproportionate to the situation. They indicate damage to the brain regions that regulate emotions, such as the frontal lobe, the thalamus, or the brainstem. Therefore, this finding does not indicate effective early intervention for ischemic stroke.
Choice B: Tearful sharing of stories. This is a correct answer because it indicates that the patient has improved social and emotional functioning after the ischemic stroke. Tearful sharing of stories is a normal and healthy way of expressing emotions and coping with stress. It also shows that the patient has preserved memory and language skills, which are often impaired by ischemic stroke. Early intervention with psychological support and counseling can help the patient deal with the emotional impact of stroke and improve their quality of life. Therefore, this finding indicates effective early intervention for ischemic stroke.
Choice C: Angry outburst. This is an incorrect answer because it indicates that the patient has mood disturbances, which is another common complication of ischemic stroke. Mood disturbances are changes in the patient's emotional state, such as depression, anxiety, irritability, or aggression. They indicate damage to the brain regions that regulate mood, such as the frontal lobe, the amygdala, or the hippocampus. Therefore, this finding does not indicate effective early intervention for ischemic stroke.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Pupillary changes to ipsilateral dilation indicate increased intracranial pressure, which is a life-threatening complication of stroke. The nurse should notify the physician and prepare for emergency measures.
Choice B reason: Left-sided facial drooping and dysphagia are common signs of right hemisphere stroke, but they do not require immediate intervention by the nurse. The nurse should monitor the patient's swallowing ability and provide oral care.
Choice C reason: Orientation to person and place only is a sign of impaired cognition, which is also common in right hemisphere stroke. The nurse should assess the patient's memory, judgment, and attention span.
Choice D reason: Unequal bilateral hand grip strengths are a sign of hemiparesis, which is a weakness on one side of the body. The nurse should assist the patient with mobility and prevent contractures.
Correct Answer is ["A","B", "C","D"]
Explanation
- Choice A: Occupational therapist. This is correct because an occupational therapist can help the client with activities of daily living (ADLs) such as dressing, grooming, eating, and toileting. The client may have difficulty performing these tasks due to the facial droop and weakness caused by the stroke.
- Choice B: Speech therapist. This is correct because a speech therapist can help the client with communication and swallowing problems. The client has garbled speech, which indicates a possible aphasia or dysarthria. The client may also have dysphagia, which is difficulty swallowing, due to the impaired coordination of the muscles involved in swallowing.
- Choice C: Case manager. This is correct because a case manager can coordinate the client's care and discharge planning. The case manager can arrange for referrals, home health services, equipment, and follow-up appointments as needed. The case manager can also provide education and support to the client and family.
- Choice D: Physical therapist. This is correct because a physical therapist can help the client with mobility and balance issues. The client may have hemiparesis or hemiplegia, which is weakness or paralysis of one side of the body. The physical therapist can assist the client with exercises, gait training, and assistive devices to improve the client's functional status.
- Choice E: Chief nursing officer. This is incorrect because a chief nursing officer is not directly involved in the client's recovery. A chief nursing officer is a senior-level executive who oversees the nursing staff and operations of a health care organization. A chief nursing officer may have a role in quality improvement, policy development, and strategic planning, but not in individual client care.
- Choice F: Pharmacy technician. This is incorrect because a pharmacy technician is not directly involved in the client's recovery. A pharmacy technician is a health care professional who assists pharmacists with dispensing medications and other tasks. A pharmacy technician may have a role in preparing, labeling, and delivering medications, but not in providing therapy or education to the client.
- Choice G: Respiratory therapist. This is incorrect because a respiratory therapist is not directly involved in the client's recovery. A respiratory therapist is a health care professional who provides respiratory care to patients with breathing problems. A respiratory therapist may have a role in administering oxygen, nebulizers, ventilators, and other respiratory treatments, but not in addressing the client's stroke-related impairments.
- Choice H: Medical assistant. This is incorrect because a medical assistant is not directly involved in the client's recovery. A medical assistant is a health care professional who performs administrative and clinical tasks in a medical office or clinic. A medical assistant may have a role in scheduling appointments, taking vital signs, drawing blood, and performing basic laboratory tests, but not in providing rehabilitation or education to the client.
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