A client is brought to the emergency department with symptoms of a cerebrovascular accident (CVA). The nurse would anticipate which diagnostic evaluation to be completed prior to initiation of treatment?
Prothrombin level
Chest x-ray
Brain CT scan or MRI
Lumbar puncture
The Correct Answer is C
A. Prothrombin level: Although checking coagulation levels like prothrombin time may be important, it is not the first-line diagnostic tool for determining the type of stroke (ischemic or hemorrhagic), which is critical for treatment decisions.
B. Chest x-ray: A chest x-ray is not directly related to diagnosing or determining the type of stroke. It may be used for other purposes, such as assessing for respiratory issues, but it is not the priority in stroke diagnosis.
C. Brain CT scan or MRI: A brain CT scan or MRI is the most crucial diagnostic test to perform before initiating treatment for a stroke. This imaging helps differentiate between ischemic and hemorrhagic stroke, guiding the appropriate treatment approach.
D. Lumbar puncture: A lumbar puncture may be used in certain neurological evaluations but is not the first-line test for diagnosing a stroke. It is invasive and not typically performed in the acute setting for stroke evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B"]
Explanation
A. blurred vision: Blurred vision is a common side effect of tricyclic antidepressants due to their anticholinergic effects, and it can be a sign of overdose.
B. urinary retention: Urinary retention is another anticholinergic side effect of tricyclic antidepressants and can indicate an overdose.
C. diarrhea: Diarrhea is not typically associated with tricyclic antidepressant overdose. Anticholinergic effects generally lead to constipation, not diarrhea.
D. headache: While a headache can occur in many situations, it is not a specific indicator of tricyclic antidepressant overdose.
E. pale, moist skin: Pale, moist skin is not a typical symptom of tricyclic antidepressant overdose. Overdose symptoms more commonly include dry skin due to anticholinergic effects.
Correct Answer is B
Explanation
A. Maintaining accurate records of intake and output: While monitoring intake and output is important for assessing fluid balance and kidney function, it is not as immediate a concern as maintaining an airway in an unconscious client.
B. Maintaining a patent airway: This is the highest priority because an unconscious client is at high risk of airway obstruction due to the loss of protective reflexes. Ensuring that the airway remains open is critical to prevent respiratory distress or arrest.
C. Inserting a nasogastric (NG) tube as prescribed: Inserting an NG tube might be necessary for feeding or draining gastric contents, but it is secondary to the more urgent need of ensuring a clear airway.
D. Providing appropriate pain control: Pain control is important but should be considered after addressing more immediate threats to the client's safety, such as maintaining a patent airway.
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