. Which observation supports the possibility that a patient who has experienced a stroke has aspirated? (Select all that apply.)
a. Regurgitation in the mouth
b. Vomiting
c. Hoarseness
d. Reports of nausea
e. Coughi
...
. Which observation supports the possibility that a patient who has experienced a stroke has aspirated? (Select all that apply.)
a. Regurgitation in the mouth
b. Vomiting
c. Hoarseness
d. Reports of nausea
e. Coughing
2. A patient with dysphagia following a stroke expresses concern about having difficulty eating and drinking. What is the appropriate reply by the nurse?
a. Muscle weakness frequently occurs after a stroke; we need to make sure that food is not going into your lungs.
b. You will need to ask your provider
c. You sound worried; tell me more about your concerns
d. We need to make sure your GI tract is working prior to giving you food
3. When taking a patient's health history, which of the following does the nurse identify as risk factors for having a stroke? (Select all that apply.)
a. Hypertension
b. Recent weight loss
c. Smoking
d. Asthma
e. Diabetes mellitus
4. The nurse has an order to complete neurochecks every four hours. Which assessments would the nurse include in the neurological examination? (Select all that apply.)
a. Cranial nerves
b. Range of motion
c. Level of consciousness
d. Sensory perception
e. Memory
5. The nurse is caring for four medical-surgical patients. Which patient should be assessed using the Glasgow Coma Scale?
a. An 85 year old patient with dementia and increasing confusion
b. A 47 year old patient who suffered a brain injury and lost consciousness in a MVA
c. A 51 year old patient with cancer who is experiencing episodes of anxiety and depression
d. A 32 year old patient who is paraplegic and has pneumonia
6. The nurse is caring for a patient who is suspected of having a stroke. What should be the nurse's first action to ensure patient safety when it appears the patient is having difficulty swallowing prescribed oral medication?
a. Schedule an immediate speech therapist swallow study
b. Educate the patient to the substantial risk of aspiration associated with a stroke
c. Hold this dose of medication and make the patient NPO
d. Notify the provider of the suspected problem
7. A patient is experiencing dysphagia following a stroke. How should the nurse position the patient when administering medications?
a. Supine
b. Left lateral
c. High Fowler's
d. Semi-Fowler's
8. Mr. Russell has been placed on fall precautions. What actions should the nurse take to keep the patient safe? (Select all that apply.)
a. Place the call bell within reach
b. Keep side rails up x 4 at all times
c. Provide non-skid socks for ambulation
d. Maintain bed in low position at all times
e. Instruct the patient to call for assistance when out of bed
9. A patient has been admitted with a diagnosis of stroke, and the nurse has received orders to hold warfarin until lab results are received. What lab result does the nurse anticipate reviewing prior to administering this medication?
a. D-dimer
b. PT/INR
c. Platelets
d. H & H
10. The nurse is caring for a patient who has experienced a sudden change in LOC and has difficulty speaking. What is the priority action of the nurse?
a. Document the findings
b. Assess the patient
c. Notify the charge nurse
d. Wait 15 minutes to see if the problem resolves
11. Mr. Russell experienced dysphagia and mild left-sided weakness following his stroke. For which additional symptoms of stroke should the nurse assess? (Select all that apply.)
a. Sensory deficits
b. Hearing loss
c. Urinary incontinence
d. Communication difficulties
e. Decreased peristalsis
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