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 D
Explanation
Choice A reason: Measuring capillary glucose level is not a priority action for a client with a rigid abdomen and rebound tenderness. These signs indicate peritonitis, which is a serious complication of IBD that requires immediate attention. Corticosteroids can increase blood glucose levels, but this is not an urgent concern in this situation.
Choice B reason: Encouraging ambulation in the room is not appropriate for a client with a rigid abdomen and rebound tenderness. These signs indicate peritonitis, which is a serious complication of IBD that requires immediate attention. Ambulation can worsen the pain and inflammation, and increase the risk of bowel perforation.
Choice C reason: Monitoring for bloody diarrheal stools is important for a client with IBD, but not a priority action for a client with a rigid abdomen and rebound tenderness. These signs indicate peritonitis, which is a serious complication of IBD that requires immediate attention. Bloody stools can be a sign of ulceration or bleeding in the bowel, but they are not specific to peritonitis.
Choice D reason: Obtaining vital sign measurements is the priority action for a client with a rigid abdomen and rebound tenderness. These signs indicate peritonitis, which is a serious complication of IBD that requires immediate attention. Vital signs can reveal signs of infection, inflammation, shock, and organ failure, which can guide the appropriate interventions and treatments.
Correct Answer is C
Explanation
Choice A reason: A referral for social services at home is not necessary for a client with Addison's disease who has stable vital signs, adequate hydration, and good self-care knowledge.
Choice B reason: Limiting daily fluid intake to 500 mL is not appropriate for a client with Addison's disease, who is at risk of dehydration and hypotension. The client should drink fluids according to thirst and urine output.
Choice C reason: Preparing the client for discharge home is the best action for the nurse to implement, as the client has no signs of complications or deterioration from Addison's disease. The client should be able to manage the condition at home with regular follow-up and medication adherence.
Choice D reason: Strict intake and output monitoring is not required for a client with Addison's disease who has normal blood pressure, moist mucous membranes, and strong peripheral pulses. These indicate adequate fluid balance and renal function.
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