The nurse is caring for a 72-year-old patient brought to the ED with severe headache and decreasing level of consciousness. The nurse reviews the patient's assessment data to prepare the plan of care.

Exhibits

Complete the bowtie by dragging and dropping the condition the patient is most likely experiencing, two interventions the nurse would perform/anticipate related to the condition, and two parameters the nurse would monitor.

Answer and Explanation

The Correct Answer is []

Condition the Patient is Most Likely Experiencing:

Intracerebral Haemorrhage (ICH) : The patient presents with a severe headache, lethargy, decreased level of consciousness, and slurred, incomprehensible speech, which are common signs of a stroke or intracerebral haemorrhage. A history of hypertension and atrial fibrillation increases the risk for both ischemic and hemorrhagic strokes. The use of apixaban, an anticoagulant, suggests the patient is at risk for bleeding complications, including intracerebral haemorrhage.

Interventions to Perform/Anticipate:

Perform a CT Scan of the Head:
- Rationale: A CT scan will help determine if there is bleeding or an ischemic event in the brain. It is crucial for differentiating between ischemic and hemorrhagic stroke, guiding subsequent treatment.
Administer Intravenous Antihypertensives:
- Rationale: Controlling blood pressure is critical to reduce the risk of further bleeding in the brain. Immediate BP management is essential in the acute setting of suspected stroke.

Parameters to Monitor:

Neurological Status:
- Rationale: Monitoring changes in the patient’s level of consciousness, pupil reactions, and motor response will help assess the progression of the neurological deficit and effectiveness of interventions.
Blood Pressure:
- Rationale: Maintaining blood pressure within a safe range is essential to prevent exacerbation of the hemorrhage. Hypertension management is key to avoid further complications.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Correct answer: A
A. The right leg for shortening: This is the most critical observation because crossing the legs after a hip replacement can cause hip dislocation. A shortened leg can be a sign of dislocation, which is a serious complication that requires immediate attention.
B. The left leg for internal rotation: Internal rotation is more of a concern for the operated leg (the right leg), not the left leg, in this context.
C. The left leg for loss of function: This is less relevant unless there is concern about a complication in the left leg, which is not directly related to the issue of crossing legs post-surgery.
D. The right knee for crepitation: Crepitation refers to a crackling sound and is more associated with joint issues rather than an indicator of hip dislocation.

A. Have the patient swallow twice after each bite. B. Place the patient in a semi-Fowler position. C. Provide clear liquids only until the patient can swallow solid foods. D. Check the patient's mouth for pocketing of food. E. Encourage the use of a straw for liquids. F. Place food on the unaffected side of the patient's mouth.

Correct Answer is ["A","D","F"]

Explanation

A. Have the patient swallow twice after each bite: This can help clear any residual food from the mouth and reduce the risk of aspiration.
B. Place the patient in a semi-Fowler position: This position is not ideal for preventing aspiration. The patient should be in an upright, high Fowler’s position to minimize the risk.
C. Provide clear liquids only until the patient can swallow solid foods: Clear liquids can actually be more difficult to control in the mouth and throat than thicker liquids and may increase the risk of aspiration.
D. Check the patient's mouth for pocketing of food: Ensuring that no food is left in the mouth can help prevent aspiration after the patient has finished eating.
E. Encourage the use of a straw for liquids: Using a straw can increase the risk of aspiration because it delivers liquids quickly and may overwhelm the swallowing mechanism, especially in patients with dysphagia.
F. Place food on the unaffected side of the patient's mouth: This helps ensure that the stronger side of the mouth and throat manages the food, reducing the risk of aspiration.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A patient is having difficulty swallowing following a stroke, and a swallowing evaluation is ordered. Which nursing interventions might be recommended to help prevent aspiration during eating? Select all that apply. (Select All that Apply.)

Correct Answer is ["A","D","F"]

Explanation

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