A client presents to the emergency department with a sudden onset of left-sided weakness, difficulty speaking, and a facial droop on the left side.
Which action should the nurse prioritize?
Obtain a CT scan of the brain without contrast.
Obtain a CT scan with contrast.
Administer a thrombolytic agent.
Begin intravenous hydration.
The Correct Answer is A
Acute stroke management requires rapid application of the time-is-brain principle. Knowledge of the differential diagnosis between ischemic and hemorrhagic strokes is vital. Practitioners must prioritize diagnostic imaging that safely identifies hemorrhage to determine if thrombolytic therapy is indicated.
Choice A rationale
A non-contrast CT scan is the gold standard for initial stroke assessment to rule out intracranial hemorrhage. It is faster than an MRI and avoids contrast, which can mimic blood or cause kidney injury in emergencies.
Choice B rationale
Contrast is avoided during the initial emergency scan because it can leak into brain tissue and appear hyperdense. This mimics the appearance of acute blood, making it difficult to distinguish between a bleed and ischemia.
Choice C rationale
Thrombolytics cannot be administered until a CT scan confirms the absence of a hemorrhage. Giving these drugs to a patient with a brain bleed would cause catastrophic worsening of the condition and potential death.
Choice D rationale
While IV access and hydration are important, they are secondary to identifying the type of stroke. Diagnostic imaging must occur first to facilitate the most time-sensitive treatments like fibrinolysis or mechanical thrombectomy for ischemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This scenario requires the application of electrocardiography interpretation skills to identify specific cardiac arrhythmias based on rhythm regularity, presence of P waves, and heart rate. Recognizing atrial fibrillation is essential for determining appropriate anticoagulation and rate control interventions for telemetry clients.
Choice A rationale
Atrial fibrillation is characterized by an irregularly irregular rhythm and a lack of discernible P waves. The rapid, disorganized electrical activity in the atria leads to ineffective pumping and increased risk for thromboembolic events or symptomatic palpitations.
Choice B rationale
Sinus tachycardia follows a regular rhythm with identifiable P waves preceding every QRS complex. The rate is typically between 101 and 150 beats per minute. This does not match the irregularly irregular rhythm or absent P waves described.
Choice C rationale
First degree heart block involves a delayed conduction through the atrioventricular node, resulting in a prolonged PR interval greater than 0.20 seconds. However, the rhythm remains regular with a 1 to 1 ratio of P waves to QRS.
Choice D rationale
Ventricular tachycardia presents as three or more consecutive premature ventricular contractions with a rate usually exceeding 100 per minute. It shows wide, bizarre QRS complexes and is typically a regular rhythm, which is inconsistent with this client strip.
Correct Answer is A
Explanation
Dexamethasone is a potent corticosteroid used to reduce cerebral edema in brain tumor patients. Prioritizing care requires identifying life-threatening neurological changes or severe medication side effects, applying knowledge of intracranial pressure, glucose metabolism, and the hierarchy of clinical needs.
Choice A rationale
Acute loss of orientation to self indicates a significant decline in neurological status or increased intracranial pressure. This is a medical emergency requiring immediate intervention to prevent brain herniation, outweighing stable physical side effects of steroid therapy.
Choice B rationale
Weight gain is a common side effect of long-term dexamethasone use due to fluid retention and increased appetite. While it requires monitoring, it is an expected systemic effect and does not represent an immediate life-threatening crisis.
Choice C rationale
Insomnia is a known side effect of corticosteroids because they can interfere with the circadian rhythm and stimulate the central nervous system. It affects the client's comfort but does not indicate immediate physiological or neurological compromise.
Choice D rationale
Glucocorticoids cause hyperglycemia; 350 mg/dL is high compared to the normal fasting range of 70 to 100 mg/dL. While it requires insulin or dosage adjustment, it is less urgent than an acute neurological deficit..
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