Final: case study questions

Question 1

1. A client was brought into the ED with signs of a stroke. Results from a CT of the brain ordered by the provider show no hemorrhage and confirmed an ischemic stroke (left middle cerebral artery). The client’s symptoms began 30 minutes ago. Which of these are priority nursing actions for the treatment of this client (select all that apply):

A. Monitoring the client’s level of consciousness
B. Immediate administration of IV fibrinolytic therapy
C. Obtaining and recording hourly blood glucose levels
D. Providing education about the administration of Warfarin
E. Monitoring the client’s blood pressure
F. Teaching the client about a low-cholesterol diet

Answer 1

A, B, E

Question 2

2. A nurse caring for a client diagnosed with an ischemic stroke. The nurse goes in to examine the client and the client continuously complains of a headache at a 10/10 on the pain scale. The client’s vitals come up as temp- 99.2, B/P- 220/110, pulse 115, R-22, O2- 93%. What is going to be the nurse’s first action for this client?

A. Give 10 mg carvedilol
B. Assess the patient’s pupils
C. Perform NIH scale quickly
D. Lower the head of the bed

Answer 2

B

Question 3

3. The nurse is caring for a patient with a suspected ischemic stroke and alteplase is to be administered at 1400. The nurse questions this order if which of the following is true? (select all that apply):

A. Last known well at 1020
B. CT scan results pending
C. Client provided written consent
D. Client’s home medications include warfarin last taken that morning
E. Blood pressure is 120/94

Answer 3

A, B, D

Question 4

What type of insulin is the physician most likely to order for a patient with DKA?

A. SQ NPH
B. IV Regular
C. SQ Levemir
D. IV Novolog

Answer 4

B

Question 5

You are providing care to a 28-year-old female in DKA. The patient is on an insulin drip and their current glucose level is 300. In addition to this, the patient also has 5% Dextrose 0.45% NS infusing in a right 20-gauge AC PIV. Which of the following complaint/assessment is cause for concern?

A. Patient complains of thirst.
B. Patientpotassium level of 2.3
C. Patient’s skin and mucous membranes are dry.
D. Patient is nauseated with increased abdominal pain of 8/10

Answer 5

B

Question 6

What are common risk factors for DKA? (SATA)

A. Alcohol and/or drug use
B. Hypotension
C. New onset diabetes
D. Alopecia
E. Illness or infection
F. Certain medications (corticosteroids, Diabetes medications, Diuretics)

Answer 6

A, C, E, F