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","D","E"]
Explanation
The primary survey in trauma management focuses on life threatening conditions using the airway, breathing, circulation, disability, and exposure sequence. Knowledge of emergency stabilization techniques is required to prioritize rapid assessment and immediate interventions for physiological survival during the initial encounter.
Choice A rationale
Cervical spine stabilization prevents permanent spinal cord injury during airway management. In trauma, any mechanism of injury involving high velocity or impact requires strict spinal precautions until the spine is radiographically cleared or physically assessed for stability.
Choice B rationale
Obtaining a comprehensive history is part of the secondary survey, specifically the AMPLE assessment. The primary survey focuses only on immediate life threats and physiological stabilization, delaying detailed data collection until the client is determined to be stable.
Choice C rationale
Elevating the head of the bed may compromise spinal alignment before clearance and is not a priority in the ABCDE sequence. Management typically focuses on maintaining a flat, supine position on a backboard to protect the spine.
Choice D rationale
The Glasgow Coma Scale assessment is a core component of the disability portion of the primary survey. It provides a standardized method to evaluate neurological status, including eye opening, verbal response, and motor response to stimuli.
Choice E rationale
Prevention of hypothermia is the exposure and environment stage of the primary survey. Maintaining normothermia is vital because hypothermia can lead to coagulopathy and metabolic acidosis, forming a lethal triad that significantly increases trauma mortality..
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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