A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38.2° C (100.8° F). Which of the following neurologic disorders should the nurse suspect?
Thrombotic stroke
Transient ischemic atack (TIA)
Embolic stroke
Hemorrhagic stroke
The Correct Answer is D
Hemorrhagic stroke is a type of stroke that occurs when a blood vessel ruptures in the brain, causing bleeding and increased intracranial pressure. The client's symptoms of sudden, severe headache, vomiting, seizure, and
unresponsiveness are consistent with hemorrhagic stroke. The client's elevated blood pressure and temperature are also risk factors for hemorrhagic stroke.
Thrombotic stroke is a type of stroke that occurs when a blood clot forms in an artery that supplies blood to the brain, causing ischemia and tissue damage. The client's symptoms are not typical of thrombotic stroke, which usually has a gradual onset and affects one side of the body.
Transient ischemic atack (TIA) is a temporary interruption of blood flow to the brain, causing neurologic deficits that resolve within 24 hours. The client's symptoms are not indicative of TIA, which does not cause loss of consciousness or permanent brain damage.
Embolic stroke is a type of stroke that occurs when a blood clot or other debris travels from another part of the body to the brain, causing occlusion and ischemia. The client's symptoms are not characteristic of embolic stroke, which usually has a sudden onset and affects one side of the body.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Asthma typically presents with wheezing, shortness of breath, and chest tightness. While dyspnea is a symptom, tachycardia and weak peripheral pulses are not characteristic findings associated with asthma.
B. Aortic valve regurgitation may cause dyspnea and fatigue, but it is more commonly associated with bounding pulses and diastolic murmur rather than weak peripheral pulses.
C. Heart failure is characterized by symptoms such as dyspnea, fatigue, tachycardia, and weak peripheral pulses due to reduced cardiac output and poor perfusion to the extremities. The nurse should recognize these signs as indicative of heart failure.
D. Aortic stenosis can lead to symptoms like dyspnea and fatigue; however, it typically presents with a triad of symptoms including exertional dyspnea, angina, and syncope, rather than weak peripheral pulses.
Correct Answer is C
Explanation
Obtaining a pair of slipper socks for the client is a simple and safe way to provide warmth and insulation to the feet, which can improve blood flow and comfort.
Placing a moist heating pad under the client's feet is not recommended, as it can cause burns, vasodilation, or increased fluid loss, which can worsen the condition.
Increasing the client's oral fluid intake is not relevant, as it does not affect the temperature or circulation of the feet.
Rubbing the client's feet briskly for several minutes is not advisable, as it can cause trauma, inflammation, or ulceration to the fragile skin and tissues of the feet.
Obtaining a pair of slipper socks for the client is a simple and safe way to provide warmth and insulation to the feet, which can improve blood flow and comfort.
Placing a moist heating pad under the client's feet is not recommended, as it can cause burns, vasodilation, or increased fluid loss, which can worsen the condition.
Increasing the client's oral fluid intake is not relevant, as it does not affect the temperature or circulation of the feet.
Rubbing the client's feet briskly for several minutes is not advisable, as it can cause trauma, inflammation, or ulceration to the fragile skin and tissues of the feet.
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