A client presents with a sudden onset of a severe headache, confusion, and facial drooping.
The nurse is reviewing the Medication Administration Record and potential provider orders. Which potential condition is the client most likely experiencing?

Migraine Headache.

Stroke.

Trigeminal Neuralgia.

Meningitis.

Answer and Explanation

The Correct Answer is B

This scenario requires differentiating between various neurological conditions based on the sudden onset of focal deficits and altered mental status. Recognizing the hallmarks of acute ischemia or hemorrhage is vital for ensuring the patient receives rapid, time sensitive reperfusion therapies.

Choice A rationale

Migraines typically present with unilateral throbbing pain, photophobia, and phonophobia, often preceded by an aura. While they can be severe, they do not usually cause acute facial drooping or the profound confusion associated with a cerebrovascular accident.

Choice B rationale

A stroke involves a sudden interruption of blood flow to the brain, causing rapid onset focal neurological deficits. Facial drooping, confusion, and severe headache are classic signs of either ischemic or hemorrhagic events requiring immediate emergency diagnostic imaging.

Choice C rationale

Trigeminal neuralgia is characterized by sudden, brief, and excruciating paroxysmal facial pain along the branches of the fifth cranial nerve. It does not cause confusion, facial drooping, or a generalized severe headache, as it is a sensory nerve disorder.

Choice D rationale

Meningitis involves inflammation of the meninges, typically presenting with fever, nuchal rigidity, and photophobia. While confusion and headache occur, the onset is usually more gradual than a stroke and does not typically include acute focal facial drooping.

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Free Nursing Study Resources

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

Explanation

Diagnosing acute pancreatitis involves analyzing inflammatory markers, pancreatic enzymes, and metabolic changes. Knowledge of systemic inflammatory response syndrome and the endocrine/exocrine functions of the pancreas is necessary to identify labs indicating tissue necrosis, inflammation, and secondary metabolic disturbances.

Choice A rationale

Pancreatitis triggers a systemic inflammatory response, leading to leukocytosis. An elevated white blood cell count (normal range 5,000 to 10,000 cells/mm) is a common finding indicating active inflammation or secondary infection within the pancreatic tissue.

Choice B rationale

In acute pancreatitis, hematocrit often increases rather than decreases due to hemoconcentration. Fluid shifts from the intravascular space into the peritoneal cavity (third spacing) cause a relative rise in hematocrit, indicating significant volume depletion.

Choice C rationale

Serum amylase (normal range 30 to 110 U/L) typically increases rapidly within hours of symptom onset in pancreatitis. A decreased level is not supportive of this diagnosis; levels usually rise three times the upper limit.

Choice D rationale

Serum lipase (normal range 0 to 160 U/L) is a highly specific marker for pancreatic damage. In acute pancreatitis, lipase levels rise significantly and remain elevated longer than amylase, making it a primary diagnostic indicator.

Choice E rationale

Hypertriglyceridemia is both a cause and a result of acute pancreatitis. Serum triglycerides exceeding 1,000 mg/dL can precipitate an attack. Elevated levels support the diagnosis and help identify the potential underlying metabolic etiology.

Choice F rationale

The pancreas produces insulin via islets of Langerhans. Inflammation impairs endocrine function, leading to hyperglycemia (normal fasting glucose 70 to 99 mg/dL). Elevated glucose is a common secondary finding in acute pancreatic injury.

Correct Answer is ["2300"]

Explanation

Step 1 is (25,000 units ÷ 250 mL) × 23 mL = 2,300 units per hour.

Final calculated answer is 2,300.

View Question and Answer

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A client presents with a sudden onset of a severe headache, confusion, and facial drooping. The nurse is reviewing the Medication Administration Record and potential provider orders. Which potential condition is the client most likely experiencing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the lab results of a client with suspected acute pancreatitis. Which additional lab results would support this diagnosis? Select all that apply.

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

Explanation

The client is receiving a continuous heparin drip 25,000 units/250 mL D5W, at 23 mL/hr. How many units of heparin is the client receiving an hour? Round answer to the nearest whole number.

Correct Answer is ["2300"]

Explanation

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A client presents with a sudden onset of a severe headache, confusion, and facial drooping.
The nurse is reviewing the Medication Administration Record and potential provider orders. Which potential condition is the client most likely experiencing?