Case Study Brain Attack (Stroke)

Hi! I'm working on the Hesi case study for Brain Attack, and I need help. Here are the questions:


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 carotid bruit.
    Elevated blood pressure.
    Hyperreflexic deep tendon reflexes.
    Decreased bowel sounds.
    Difficulty swallowing.

The ED physician has completed an assessment. Gail is sitting at the bedside while the ED nurse continues to assess Nancy every 15 minutes.
2.
Which assessment finding warrants immediate intervention by the nurse?

    Nancy’s Glasgow Coma Scale (GCS) score increases.
    Nancy’s bilateral grip strength is unequal.
    Nancy only responds to painful stimuli.
    Nancy has a negative Babinski's reflex bilaterally.

Thanks!

Post Merge: 10 years ago

Lastly, this one pleas:

Legal Issues

Nancy appears depressed, and Gail reports that her mother seems to have lost all hope. Gail reminds the staff that her mother has a Living Will and a Do Not Resuscitate order. Gail has a Durable Power of Attorney for Health Care that was signed over 2 years ago.

A week later, Gail is sitting at the bedside when Nancy starts to gasp for air. Gail yells for the nurse. When the nurse arrives, Nancy is not breathing. The nurse assesses Nancy's apical pulse but cannot hear anything.
27.
Which intervention should the nurse implement?

    Call a code immediately and reposition Nancy's airway.
    Continue to stay at Nancy's bedside and hold Gail's hand.
    Provide Nancy with 2 rescue breaths and assess the carotid pulse.
    Turn Nancy to the left lateral position and assess the apical heart rate.

I got all the others.