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 ["125"]
Explanation
To calculate the infusion rate, the nurse should use the following formula:
Infusion rate (mL/hr) = Volume (mL) / Time (hr)
Plugging in the given values, the nurse should get:
Infusion rate (mL/hr) = 250 mL / 2 hr
Infusion rate (mL/hr) = 125 mL/hr
The nurse should round the answer to the nearest whole number and use a leading zero if it applies. Therefore, the nurse should set the IV pump to deliver 125 mL/hr.
Correct Answer is D
Explanation
Using elastic stockings is an effective way to improve venous return and prevent edema, stasis, and ulceration in clients who have venous insufficiency. The stockings should be applied before getting out of bed and worn throughout the day.
"Apply ice packs to your legs." is not appropriate, as ice packs can cause vasoconstriction and impair blood flow to the legs, worsening the condition.
"Place your legs in a dependent position while in bed." is not advisable, as dependent position can increase venous pressure and fluid accumulation in the legs, leading to edema, pain, and skin breakdown
"Remain on bed rest." is not necessary, as bed rest can reduce muscle contraction and impair venous return. The client should be encouraged to perform regular exercise, such as walking, to enhance circulation and prevent complications.
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