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. Ascites B. Alopecia C. Generalized edema D. Petechiae E. Epistaxis

Correct Answer is ["D","E"]

Explanation

A) Ascites
Ascites, the accumulation of fluid in the peritoneal cavity, is not a typical initial assessment finding in acute lymphocytic leukemia (ALL). While ascites can occur in some cancers or in cases of liver failure, it is not a hallmark or common finding in ALL. The focus in ALL would generally be on hematologic and immunologic symptoms rather than fluid accumulation in the abdomen.

B) Alopecia
Alopecia (hair loss) is more commonly associated with chemotherapy treatment for leukemia rather than the leukemia itself. While chemotherapy for ALL can lead to hair loss, it is not typically an initial symptom of the disease itself. Alopecia may appear later, as a side effect of cancer treatment.

C) Generalized edema
Generalized edema (swelling) is not a common or early sign of acute lymphocytic leukemia. While edema can occur in certain malignancies or complications (like in cases of renal failure or heart failure), it is not typically an initial presenting symptom of ALL. The key manifestations of ALL tend to relate to hematologic abnormalities, rather than fluid accumulation.

D) Petechiae
Petechiae (small, red or purple spots on the skin) are a common finding in ALL. They occur due to thrombocytopenia (low platelet count), which is a hallmark of leukemia. Thrombocytopenia impairs the blood’s ability to clot, leading to bleeding under the skin. Petechiae is often one of the first visible signs of blood dyscrasia in leukemia patients.

E) Epistaxis
Epistaxis (nosebleeds) is another common initial finding in ALL. Like petechiae, epistaxis occurs due to thrombocytopenia, which impairs normal clotting and leads to spontaneous bleeding. Nosebleeds are frequently observed in patients with low platelet counts, especially in leukemia.

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

Nursing Test Bank

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Correct Answer is C

Explanation

Which initial assessment findings would the nurse expect in a client diagnosed with acute lymphocytic leukemia ALL? (SELECT ALL THAT APPLY)

Correct Answer is ["D","E"]

Explanation

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