The client is a 63-year-old female who arrived via emergency services with right-sided weakness, right facial droop, and slurred speech. History and Physical History: Diabetes mellitus type II, hypertension, and rheumatoid arthritis. Spouse is answering questions for her at the bedside. Per spouse, the client has experienced recent increased stress and does not monitor her blood pressure. The client was in her usual health the night prior. She woke up around 0500 and having a typical morning until approximately 0630 when she noticed that she wasn’t able to hold her brush with her right hand. Spouse states he noticed that her face was also drooping at that time and called 911. Nurses Note: 07/05/20XX 0712: Client arrived and stroke alert initiated. Client is alert and oriented x 3 with slurred speech and aphasia. Client unable to lift or maintain gravity in right arm and right leg. Drooping to the right side of the face noted. Healthcare provider at bedside. Nurses Note 7/5/20XX 0745: The client is able to speak a few words and states that she has a history of atrial fibrillation and her gallbladder removed 4 months ago. The client begins to moan, hold her head, and complains of extreme pain in the back of her head. The lab has called with the stat laboratory results: Lab Result Reference Range White blood cell 6.4 4.5-11 per microliter Hemoglobin 13.3 12-16 g/dL Hematocrit 39 38-46% Platelet 180,000 150,000-45000/microliter PT 11 11-13.5 seconds INR 1.1 0.8-1.2 Vitals 07/05/20XX 0712: Temp: 98.6*F Pulse: 99 Respirations: 22 Blood Pressure: 180/118 O2 Saturation: 98% on Room Air 07/05/20XX 0810 – Client to radiology for CT without contrast. CT results: no evidence of hemorrhage. 07/05/20XX 0820: Client returns from Radiology and placed on bedside telemetry monitoring. Client remains in Atrial fibrillation. Healthcare provider at the bedside and orders to lower the blood pressure before administering thrombolytic to reduce the risk of hemorrhage. 07/05/XX 0830 – Client resting quietly. Right side remains weak, unable to maintain gravity in right arm and right leg, speech is slurred with some word finding difficulty. Client is frustrated and tearful. Remains in A-fib on the monitor with a rate of 90. Healthcare provider orders to administer thrombolytic – Tenecteplase 20 mg IV. Vitals: Temp: 98.6*F Pulse 90 Respirations: 20 Blood Pressure: 141/89 Oxygen Saturation: 98% on Room Air. 07/05/XX 0910 – Client is now able to maintain gravity in all extremities, slurred speech continues with dysarthria noted. Client denies pain or discomfort, lungs are clear with no shortness of breath, has urinated with assistance on bedpan, urine clear and yellow. Orders for admission to ICU for further monitoring. Vitals: Temp: 98.6*F Pulse 88 Respirations: 20 Blood Pressure: 138/82 Oxygen Saturation: 98% on Room Air. NIHSS: 4 The client is steadily improving and will likely stay for 3-4 days depending upon her continued improvement. During her hospital stay, which diagnostic tests does the nurse anticipate to be ordered in effort to determine the cause of the stroke? Select all that apply.
A nurse performs an admission assessment on a client with a…
A nurse performs an admission assessment on a client with a diagnosis of tuberculosis (TB). Which diagnostic test that will provide the most rapid and accurate result for TB?
A client is admitted after a motorcycle accident with multip…
A client is admitted after a motorcycle accident with multiple traumatic injuries. The client has facial and forearm lacerations, a fractured femur, and an X-ray confirming a C7 vertebral fracture. On assessment, he is alert and oriented, pupils are equal at 5 mm and reactive to light, but he has no sensation in his legs or feet. Which nursing action is the priority?
H&P: 24 y/o healthy male comes to the emergency departme…
H&P: 24 y/o healthy male comes to the emergency department (ED) after a motor vehicle accident (MVA). Transported to the ED via a spinal backboard and with a cervical collar to maintain head and neck alignment. Per emergency services, the client was unconscious at the site of the MVA and regained consciousness after 4 minutes. Client has since awakened and is ALOx3, moving all extremities. Client c/o dull headache, dizziness, and unable to remember how the accident occurred. No visual changes, weakness, or incontinence. No significant past medical or surgical history, except for a concussion during high school while playing contact football. Denies alcohol, tobacco, or illicit drug use. Physical Assessment: 1/18/22 at 0943: VS as followed: 99.2F, Pulse: 98 and regular, Blood pressure: 134/81mmHg, and respirations: 20 and regular. ALOx3. GSC: 15. Skin has scattered bruising and scabs. Pupils equal and reactive, periorbital ecchymosis present. Heart and lung sounds normal. Head normocephalic with mild swelling to the basilar area of the head. Neck exam WNL w/ full range of motion. Abd soft, nontender, with positive bowel sounds. For each finding, specify if the finding is a risk factor or not a risk factor for spinal injury.
A client is scheduled to undergo a resection of the prostate…
A client is scheduled to undergo a resection of the prostate. When recording the health history, the nurse asks the client about his chief complaint. Which of the following complaints is the most serious symptom that can accompany benign prostatic hypertrophy (BPH)?
A nurse is caring for a client who reports to the clinic for…
A nurse is caring for a client who reports to the clinic for laboratory tests. The client has an acute kidney injury caused by acute tubular necrosis and asks why their glomerular filtration rate keeps decreasing. Which of the following pathophysiological changes occurring in the kidney should the nurse explain as the cause of decrease?
What role does a president play when celebrating a national…
What role does a president play when celebrating a national holiday like Christmas or Easter?
This meme tries to convey that capitalism is better than the…
This meme tries to convey that capitalism is better than the divisive nature of the equity/equality debate The makers of this meme were probably trying to convey that cultural marxism is a bad idea and voluntary choice is a good idea.
The Liberal Party currently has a minority in the House of C…
The Liberal Party currently has a minority in the House of Commons, although as of January 13, 2026 they are trying to achieve a majority of seats by convincing other party members to join them. This could be considered bribery and is certainly against the will of the voters in the last election.
Which of the following is an example of a body structure or…
Which of the following is an example of a body structure or function impairment related to an orthopedic condition?