10/18/24, 4:12 PM
HESI Case Study; Older Adult with Stroke
Exam with complete solution
Terms in this set (39)
Meet the Client **
At approximately 8:00 am, the client's
spouse finds him on the floor of his
bedroom. The spouse calls 911 and states
that the client has difficulty speaking and
he is not able to get himself off the floor.
When trying to roll him to his back, the
right side of his body appears limp and
weak. When the EMS team arrives, one
performs an assessment while the other
asks about the client's health history. The
client is overweight, sedentary, smokes,
drinks multiple alcoholic beverages every
day, has arthritis, and has had hypertension
and transcient ischemic attacks (TIA) for
years. The paramedics perform a Cincinnati
Pre-Hospital Stoke Scale Assessment.
Based on the assessment findings, the
paramedics call the Emergency
Department (ED) to report a suspected
stroke. En route to the hospital, an 18
gauge peripheral IV catheter is placed in
the client's left arm. He is receiving 6 liters
of oxygen via facemask and his O2
saturations remain above 95%.
1/12
, 10/18/24, 4:12 PM
Male gender.
**Stroke is more common in men than in women. However according to research
articles more men may suffer strokes, but, more women die or have more of a
**Stroke is a major public health concern in
debility compared to men if they experience a stroke.
this country. Because stroke causes major
disability and death, it is critical to identify
Heavy alcohol use.
those at risk in order to implement
**There is a known association with heavy alcohol use and strokes.
prevention strategies by targeting
modifiable risk factors.
**History of Transient Ischemic Attack (TIA).
Approximately 30% of individuals who experience a TIA have a stroke within 5 years.
What risk factors in the client's history
predispose him to stroke? (Select all that
Sedentary lifestyle.
apply. One, some, or all options may be
**Sedentary lifestyle is associated with increased risk of a stroke.
correct.)
Select all that apply
Obese and hypertensive.
**Obesity is associated with hypertension, high blood glucose, and high lipid levels.
All of these increase the risk of stroke if not controlled.
**Safe and Effective Care: Care The client sometimes forgets to take his antihypertensive medication.
ManagementThe client arrives to the ED via
ambulance at approximately 8:40 am. The **The nurse needs to question the client to know when he last took his prescribed
paramedics conduct an SBAR report to the anti-hypertensive medications. Hypertension has a mechanical effect on the integrity
ED medical staff. of the blood vessels, leading to the weakened vessel wall and/or the formation of a
thrombus which can cause a stroke to occur. The type of medication and the time he
Based on the client's history, what is the took the medication will have implications for the prescribed plan of care.
most significant piece of information that
warrants a more thorough investigation by
the nurse?
**The client is triaged and he is immediately **
assigned to the acute side of the ED. An
additional IV line with an 18 gauge
angiocath is started with an intravenous
infusion of sodium chloride 0.9% at 80
mL/hr. His weight is obtained and a 12-lead
EKG is performed. Based on his presenting
symptoms, the pharmacy is notified of the
client's admission and the potential need
for recombinant tissue plasminogen
activator (rtPA).The ED healthcare provider
(HCP) places the following prescriptions in
the electronic medical record (EMR).ALL
LABS stat
CBC without differential
Serum electrolytes
Serum glucose
BUN & creatinine
CK & troponin
Baseline ABG
Type and cross; hold
PTT, INR
DIAGNOSTICS
12 lead ECG STAT
CXR STAT
Head CT scan without contrast STAT
HESI Case Study; Older Adult with Stroke
2/12
HESI Case Study; Older Adult with Stroke
Exam with complete solution
Terms in this set (39)
Meet the Client **
At approximately 8:00 am, the client's
spouse finds him on the floor of his
bedroom. The spouse calls 911 and states
that the client has difficulty speaking and
he is not able to get himself off the floor.
When trying to roll him to his back, the
right side of his body appears limp and
weak. When the EMS team arrives, one
performs an assessment while the other
asks about the client's health history. The
client is overweight, sedentary, smokes,
drinks multiple alcoholic beverages every
day, has arthritis, and has had hypertension
and transcient ischemic attacks (TIA) for
years. The paramedics perform a Cincinnati
Pre-Hospital Stoke Scale Assessment.
Based on the assessment findings, the
paramedics call the Emergency
Department (ED) to report a suspected
stroke. En route to the hospital, an 18
gauge peripheral IV catheter is placed in
the client's left arm. He is receiving 6 liters
of oxygen via facemask and his O2
saturations remain above 95%.
1/12
, 10/18/24, 4:12 PM
Male gender.
**Stroke is more common in men than in women. However according to research
articles more men may suffer strokes, but, more women die or have more of a
**Stroke is a major public health concern in
debility compared to men if they experience a stroke.
this country. Because stroke causes major
disability and death, it is critical to identify
Heavy alcohol use.
those at risk in order to implement
**There is a known association with heavy alcohol use and strokes.
prevention strategies by targeting
modifiable risk factors.
**History of Transient Ischemic Attack (TIA).
Approximately 30% of individuals who experience a TIA have a stroke within 5 years.
What risk factors in the client's history
predispose him to stroke? (Select all that
Sedentary lifestyle.
apply. One, some, or all options may be
**Sedentary lifestyle is associated with increased risk of a stroke.
correct.)
Select all that apply
Obese and hypertensive.
**Obesity is associated with hypertension, high blood glucose, and high lipid levels.
All of these increase the risk of stroke if not controlled.
**Safe and Effective Care: Care The client sometimes forgets to take his antihypertensive medication.
ManagementThe client arrives to the ED via
ambulance at approximately 8:40 am. The **The nurse needs to question the client to know when he last took his prescribed
paramedics conduct an SBAR report to the anti-hypertensive medications. Hypertension has a mechanical effect on the integrity
ED medical staff. of the blood vessels, leading to the weakened vessel wall and/or the formation of a
thrombus which can cause a stroke to occur. The type of medication and the time he
Based on the client's history, what is the took the medication will have implications for the prescribed plan of care.
most significant piece of information that
warrants a more thorough investigation by
the nurse?
**The client is triaged and he is immediately **
assigned to the acute side of the ED. An
additional IV line with an 18 gauge
angiocath is started with an intravenous
infusion of sodium chloride 0.9% at 80
mL/hr. His weight is obtained and a 12-lead
EKG is performed. Based on his presenting
symptoms, the pharmacy is notified of the
client's admission and the potential need
for recombinant tissue plasminogen
activator (rtPA).The ED healthcare provider
(HCP) places the following prescriptions in
the electronic medical record (EMR).ALL
LABS stat
CBC without differential
Serum electrolytes
Serum glucose
BUN & creatinine
CK & troponin
Baseline ABG
Type and cross; hold
PTT, INR
DIAGNOSTICS
12 lead ECG STAT
CXR STAT
Head CT scan without contrast STAT
HESI Case Study; Older Adult with Stroke
2/12
