Points Awarded
31.00
Points Missed
0.00
Percentage
100%

Clinical Manifestations
The Emergency Department (ED) nurse is completing the admission assessment. Nancy is alert but struggles to answer questions. When she attempts to talk, she slurs her speech and appears very frightened.

1.
Which additional clinical manifestation(s) should the nurse expect to find if Nancy's symptoms have been caused by a brain attack (stroke)? (Select all that apply.)
A) A carotid bruit.
CORRECT
The carotid artery (artery to the brain) is narrowed in clients with a brain attack (stroke). A bruit is an abnormal sound heard on auscultation resulting from interference with normal blood flow.

B) Elevated blood pressure.
CORRECT
Which response is best by the nurse?
A) "I am sorry, but what happened to your mother is confidential and I cannot give you any information."
INCORRECT
The nurse can discuss what a diagnosis means. Nancy is unable to make decisions, so the next of kin, her daughter, Gail, needs sufficient information to make informed decisions.

B) "Your mother has had a stroke, and the blood supply to the brain has been compromised."
CORRECT
The nurse has the knowledge, and the responsibility, to explain Nancy's condition to Gail.

C) "How do you feel about what the healthcare provider said?"
INCORRECT
The nurse should give facts first and then address her feelings after the information is provided.

D) "I will call the healthcare provider so he/she can talk to you about your mother's serious condition."
INCORRECT
The nurse can, and should, address Gail's lack of knowledge.

Gail starts to cry and states, "Mom was just fine last week when we went out to eat and to a show. I love my mom so much, and I am so scared. She is all I have."

7.
How should the nurse respond?
A) "I am sure everything will be all right."
INCORRECT
This response provides false reassurance and does not allow Gail to share her feelings.

B) "I know this is scary for you. Would you like to sit and talk?"
CORRECT
This therapeutic response provides acknowledgment of Gail's fears, and the nurse offers to take time to discuss the situation.

C) "I will notify