Nursing process assessment learning outcome 22 2

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Nursing Process: Assessment Learning Outcome: 22-2 Question 4 Type: MCSA A post-stroke patient is going home on oral Coumadin (warfarin). During discharge teaching, which statement by the patient reflects an understanding of the effects of this medication? 1. “I will stop taking this medicine if I notice any bruising.” 2. “I will not eat spinach while I’m taking this medicine.” 3. “It will be OK for me to eat anything.” 4. “I’ll check my blood pressure frequently while taking this medication.” Correct Answer: Rationale 1 : Bruising is a common side effect, and the drug should not be stopped unless by prescriber order. Rationale 2 : Warfarin is a vitamin K antagonist. Green, leafy vegetables contain vitamin K and will therefore interfere with the therapeutic effects of the drug. Rationale 3 : Fatty foods interfere with warfarin therapy. Rationale 4 : This medication does not affect the blood pressure. 2
Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 22-2 Question 5 Type: MCSA The nurse is teaching a wellness class and is discussing the warning signs of stroke. A patient asks, “What is the most important thing for me to remember?” Which is an appropriate response by the nurse?
2. “Keep a list of your medications.” 3. “Be alert for sudden weakness or numbness.” 4. “Call 911 if you notice a gradual onset of paralysis or confusion.” Correct Answer: 3 Rationale 1 : Family history and past medical history can be indicators for risk, but they are not warning signs of stroke. Rationale 2 : Keeping a list of medications will not assist in identifying a stroke. Rationale 3 : Warning signs of stroke include sudden weakness, paralysis, loss of speech, confusion, dizziness, unsteadiness, and loss of balance. The key word is sudden . Rationale 4 : Gradual onset of symptoms is not indicative of a stroke. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22-2 Question 6 Type: MCMA A patient has been hospitalized for scheduled repair of an intracranial aneurysm. The nurse caring for the patient prior to surgery would recognize which manifestations as indicating the aneurysm may be leaking or may have ruptured? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply.
Rationale 1 : The most common cranial nerve signs are dilated pupil, decreased mobility of the eye, and ptosis. Rationale 2 : The most common complaint is “the worst headache of my life.” Rationale 3 : Nausea is not a prodromal sign, but it may be present once rupture has occurred. Rationale 4 : Pupil dilation is a common prodromal finding. Rationale 5 : Stiff neck is not a prodromal sign of intracranial aneurysm.

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