A client diagnosed with a stroke complains of a severe headache. Which intervention would be the nursing priority?

Prepare for a STAT computed topography scan (CT)

Obtain a 12 lead electrocardiogram

Start an intravenous infusion of D5W at 100 mL/hr

Administer a nonnarcotic analgesics

Answer and Explanation

The Correct Answer is A

A) Prepare for a STAT computed tomography (CT) scan:
A severe headache in a client with a suspected stroke could be indicative of increased intracranial pressure (ICP), a hemorrhagic stroke, or another serious complication like cerebral edema. The priority intervention is to perform a CT scan to determine whether the stroke is ischemic (caused by a blockage) or hemorrhagic (caused by bleeding). This is crucial because the treatment approach for these two types of strokes differs significantly. For example, hemorrhagic strokes require immediate management to control bleeding and reduce ICP, whereas ischemic strokes may be treated with thrombolytics or other interventions. Therefore, preparing for a CT scan is the most urgent action to accurately diagnose the type of stroke and guide treatment decisions.

B) Obtain a 12-lead electrocardiogram (ECG):
While an ECG may be useful in assessing the cardiac rhythm and identifying potential arrhythmias (which can contribute to stroke risk), it is not the priority intervention in a patient with a suspected stroke and severe headache. The primary concern is to identify the type of stroke (ischemic or hemorrhagic), and a CT scan is the most direct way to do this. A 12-lead ECG can be obtained later if cardiac issues are suspected after stroke diagnosis.

C) Start an intravenous infusion of D5W at 100 mL/hr:
Starting an IV infusion of D5W (5% dextrose in water) is not an appropriate priority for a patient with a severe headache and suspected stroke. In fact, administering dextrose solutions may worsen the patient's condition in the case of a hemorrhagic stroke, as it could exacerbate cerebral edema or increase intracranial pressure. Fluid management in stroke patients should be approached cautiously, and IV fluids should be tailored to the patient's specific needs. The focus should be on imaging to determine the type of stroke before initiating interventions like IV fluids.

D) Administer a nonnarcotic analgesic:
While pain relief is important, administering a nonnarcotic analgesic (such as acetaminophen or ibuprofen) is not the priority in this situation. The patient's severe headache could be a sign of a serious complication like increased ICP or hemorrhagic stroke, which requires immediate diagnostic workup, not just pain management. Administering pain medication without understanding the underlying cause of the headache could mask symptoms and delay critical treatment.

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Correct Answer is C

Explanation

A) Intestines:
While abdominal trauma can affect the intestines, Kehr's sign, Cullen's sign, and Gray Turner's sign are more commonly associated with damage to the spleen rather than the intestines. Kehr's sign, in particular, is a hallmark of splenic injury, with pain referred to the left shoulder due to diaphragmatic irritation from blood in the peritoneum.

B) Liver:
Liver injuries often present with right upper quadrant pain, jaundice, and elevated liver enzymes. While liver injuries can cause internal bleeding, Cullen's and Gray Turner's signs are more closely associated with retroperitoneal bleeding from the spleen rather than liver injuries. Kehr's sign, which is left-sided shoulder pain, would not typically indicate a liver injury.

C) Spleen:
The spleen is the most likely abdominal organ affected in this case due to the left-sided rib fractures. When the spleen is injured (often as a result of blunt trauma), it can cause intraperitoneal hemorrhage. This bleeding can irritate the diaphragm, leading to Kehr's sign, which presents as left shoulder pain. Additionally, Cullen's sign (periumbilical bruising) and Gray Turner's sign (flank bruising) are indicative of retroperitoneal bleeding, which can occur with splenic rupture or laceration.

D) Stomach:
While stomach injuries can occur with blunt abdominal trauma, they are less likely to cause the signs and symptoms seen in this patient (Kehr's, Cullen's, and Gray Turner's signs). Stomach trauma typically leads to pain and potential perforation, but it doesn't often cause the peritoneal bleeding patterns seen with splenic injuries.

A. CD4 count of less than 200 cells/uL, (ranges 500-1800) and new diagnosis of pneumocystis pneumonia B. CD4 count of 1200 cells/uL (ranges 500-1800) and a new diagnosis hepatitis A C. low grade fever with the diagnosis of influenza A D. New atopic dermatitis and a White Blood count 11 million/mm3

Correct Answer is A

Explanation

A) CD4 count of less than 200 cells/uL, and new diagnosis of pneumocystis pneumonia:
A CD4 count of less than 200 cells/uL and the diagnosis of a severe opportunistic infection, such as pneumocystis pneumonia (PCP), are major criteria for the diagnosis of acquired immunodeficiency syndrome (AIDS). AIDS is the final stage of HIV infection, where the immune system is severely compromised, and the individual is highly susceptible to opportunistic infections like PCP, tuberculosis, and others. The CD4 count, which measures the number of immune system cells (specifically T-helper cells), is used to monitor disease progression, with values below 200 cells/uL indicating a diagnosis of AIDS.

B) CD4 count of 1200 cells/uL and a new diagnosis of hepatitis A:
While hepatitis A is an important condition that should be managed, it is not an opportunistic infection associated with AIDS. A CD4 count of 1200 cells/uL is within the normal range (500-1800 cells/uL), indicating that the immune system is not severely compromised.

C) Low grade fever with the diagnosis of influenza A:
A low-grade fever and a diagnosis of influenza A do not indicate AIDS. Influenza is a viral infection that can affect both individuals with and without HIV. It is common to experience flu-like symptoms in the early stages of HIV infection, but the presence of a fever and influenza does not confirm AIDS. A low-grade fever is also not specific to AIDS or opportunistic infections.

D) New atopic dermatitis and a white blood count of 11 million/mm³:
Atopic dermatitis is a chronic inflammatory skin condition that is not specifically associated with HIV or AIDS. The white blood cell (WBC) count of 11 million/mm³ is elevated, but this alone does not confirm a diagnosis of AIDS. Elevated WBC counts can occur with various conditions, including infections and allergic reactions, but they are not a diagnostic feature of AIDS.

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A client diagnosed with a stroke complains of a severe headache. Which intervention would be the nursing priority?

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