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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Correct Answer is B

Explanation

Understanding the clinical presentation of thermal injuries is necessary to categorize burn depth accurately. This requires knowledge of integumentary layers, including the epidermis, dermis, and subcutaneous tissues, and how specific visual markers like eschar or mottling reflect the level of tissue destruction.

Choice A rationale

First degree burns, or superficial burns, involve only the epidermis. They are characterized by redness, pain, and mild edema without blistering or eschar. The skin remains intact and dry, unlike the mottled red skin and edema seen here.

Choice B rationale

Deep partial thickness burns extend into the deeper layers of the dermis. Findings include a mottled red appearance, moderate edema, and soft, dry eschar. These wounds take longer to heal and usually require surgical intervention for optimal recovery.

Choice C rationale

Superficial partial thickness burns involve the epidermis and upper dermis. They typically present with pink, moist skin and blister formation. The presence of soft eschar and mottled red skin indicates a deeper injury than what is characteristic here.

Choice D rationale

Full thickness burns involve the entire dermis and may reach subcutaneous fat or muscle. The skin appears waxy white, leathery, or charred. While eschar is present, it is usually hard and inelastic rather than soft and mottled.

Correct Answer is ["No"]

Explanation

The correct answer is No.

Step 1 is 14 lbs ÷ 2.2 lb/kg = 6.36363636 kg.

Step 2 is 6.36 kg × 20 mg/kg/day = 127.2 mg/day for the minimum safe dose.

Step 3 is 6.36 kg × 30 mg/kg/day = 190.8 mg/day for the maximum safe dose.

Step 4 is 35 mg × (24 hours ÷ 4 hours) = 35 mg × 6 doses = 210 mg/day for the total daily dose.

Step 5 is 210 mg/day > 190.8 mg/day, which exceeds the recommended maximum daily range.

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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 client presents to the emergency department in severe pain and reports that a pot of boiling water accidentally spilled on his lower legs. The assessment reveals soft and dry eschar, mottled red skin, and moderately edematous feet. Which depth of burn should the nurse document?

Correct Answer is B

Explanation

The physician prescribes ticarcillin 35 mg IV every 4 hours for a client post kidney transplant. The client weighs 14 lbs. The nursing drug reference recommends a maximum of 20-30 mg/kg/day. Is the ordered dose for this client safe? Yes or No.

Correct Answer is ["No"]

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?