45. A client is admitted to an ICU with a possible brain attack (stroke). Assessment findings consistent with a brain attack include:
Select all that apply.
45. A client is admitted to an ICU with a possible brain attack (stroke). Assessment findings consistent with a brain attack include:
Select all that apply.
. Pronator drift.
. Facial droop.
. Slurred speech.
. Weakness of affected extremity.
. Crackles in lungs.
. Decreased urine output.
Test-Taking Tip
Select choices that are directly influenced by the sensorimotor system, not respiratory (Answer 5) or renal (Answer 6).
Content Area: Adult Health, Cardiovascular; Integrated Process: Nursing Process, Assessment; Cognitive Level: Comprehension; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Pathophysiology
. . . .
Answer 1 is correct because pronator drift reflects ischemic consequences of a stroke. Answer 2 is correct because facial droop reflects ischemic consequences of a stroke. Answer 3 is correct because slurred or garbled speech reflects ischemic consequences of a stroke. Answer 4 is correct because extremity weakness on one side reflects ischemic consequences of a stroke. Answer 5 is incorrect because crackles in the lungs would indicate CHF or pneumonia. Answer 6 is incorrect because decreased urine output would result from hypotension or impaired kidney function.