A nurse in an emergency department is caring for a client who became unresponsive after stating she had a sudden, severe headache with vomiting and then seizure activity. The client's vital signs are as follows: blood pressure of 198/110 mm Hg pulse of 82 bpm, respirations of 24/min, and a temperature of 100.8 F (38.2° C). Which neurologic disorder would the nurse suspect?

Thrombotic stroke

Embolic stroke

Hemorrhagic stroke

Transient ischemic attack (TIA)

Answer and Explanation

The Correct Answer is C

A. Thrombotic stroke. A thrombotic stroke develops more gradually and is not typically associated with such sudden and severe symptoms.

B. Embolic stroke. An embolic stroke is often associated with a known embolic source, such as a clot from the heart, and can present more suddenly, but without all the symptoms seen here.

C. Hemorrhagic stroke: Hemorrhagic strokes often present with a sudden, severe headache, vomiting, seizure activity, and high blood pressure. A fever may also develop due to increased intracranial pressure.

D. Transient ischemic attack (TIA). TIAs are brief and resolve within minutes to hours and do not typically cause seizures.

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Correct Answer is ["B","C","D","E"]

Explanation

A. Facilitates the insertion of a pacemaker: This is not the purpose of an electrophysiology study (EPS). A pacemaker may be considered based on the results, but EPS itself does not insert the device.

B. Assesses the function of the SA node: EPS is used to assess the electrical activity of the heart, including the function of the SA node.

C. Evaluates the effectiveness of prescribed antiarrhythmic medication: EPS can help evaluate how well antiarrhythmic medications are controlling arrhythmias.

D. Identifies the location of abnormal sites within cardiac muscle: EPS is often used to locate areas of the heart responsible for abnormal electrical conduction and arrhythmias.

E. Treats certain arrhythmias through the process of ablation: One of the therapeutic purposes of EPS is to perform ablation, which can treat certain arrhythmias by destroying abnormal tissue.

A. Decreased peripheral pulses B. S3 heart murmur C. Distended neck veins D. Orthopnea

Correct Answer is C

Explanation

A. Decreased peripheral pulses. Decreased pulses may be related to poor perfusion but are not a hallmark sign of right-sided heart failure.

B. S3 heart murmur. An S3 heart murmur is associated with left-sided heart failure due to fluid overload in the lungs.

C. Distended neck veins: Right-sided heart failure leads to the backup of blood in the systemic circulation, which often causes jugular vein distention (JVD), peripheral edema, and hepatomegaly.

D. Orthopnea. Orthopnea is a symptom of left-sided heart failure, where fluid builds up in the lungs, making it difficult to breathe when lying flat.

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Naxlex Comprehensive Predictor Exams

The nurse is preparing a client for an electrophysiology procedure. What statements would the nurse include when explaining this procedure to a client? Select All That Apply

Correct Answer is ["B","C","D","E"]

Explanation

The nurse is assessing a client with decompensated heart failure. Which finding would indicate that the client is manifesting right-sided heart failure?

Correct Answer is C

Explanation

A nurse is working on telemetry unit when an alarm sounds on the cardiac monitor The rhythm below is noted. What should the nurse do?

The nurse is assessing a client with unstable angina. Which finding would the nurse expect the client to report that differentiates this from other types of anginas?

The nurse is assessing a client with a head injury Which finding would indicate that the client is developing diabetes insipidus?

A nurse is preparing to administer warfarin to a client with a mechanical valve replacement. The client's INR is 2.7. Which action should the nurse implement?

The nurse is caring for a client who is on cardiac telemetry monitoring and notes that the PR interval is 0.16 seconds. Which interpretation is correct for the nurse to make?

The nurse is caring for a client with sinus bradycardia. The nurse understands that this arrhythmia may be caused by which of the following? Select All That Apply

A client with new onset right-sided weakness is admitted to the emergency department and the following orders are received. Which order should the nurse implement first?

The charge nurse is teaching a group of telemetry nurses about cardioversion. Which statement by the telemetry nurse would indicate that they understand the instruction about the electrical discharge?