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?
Embolic stroke.
Hemorrhagic stroke.
Transient ischemic attack (TIA).
Thrombotic stroke.
The Correct Answer is B
This scenario requires the application of neurovascular pathophysiology and clinical assessment skills. Understanding the distinct presentation of intracranial bleeding versus ischemic events is essential, specifically focusing on the relationship between sudden onset severe headache, projectile vomiting, and extreme hypertension in neurological emergencies.
Choice A rationale
Embolic strokes usually present with sudden focal deficits but rarely cause a thunderclap headache or significant vomiting unless brainstem involvement occurs. They result from a dislodged clot traveling to cerebral arteries, often during physical activity or exertion.
Choice B rationale
Hemorrhagic stroke involves the rupture of a blood vessel, leading to increased intracranial pressure. This pressure triggers the classic triad of sudden severe headache, vomiting, and altered consciousness, often accompanied by dangerously high blood pressure readings.
Choice C rationale
Transient ischemic attacks represent temporary blockages of blood flow that resolve within twenty-four hours without permanent damage. These episodes do not typically cause severe hypertension, vomiting, or prolonged unresponsiveness characteristic of a major intracranial event.
Choice D rationale
Thrombotic strokes are caused by gradual narrowing of an artery due to plaque, often manifesting during sleep or rest. The onset is typically slower than a hemorrhage and lacks the sudden, explosive headache and vomiting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Postoperative care focuses on mitigating risks associated with anesthesia and immobility. This question addresses the prevention of atelectasis and pneumonia by applying knowledge of respiratory mechanics, alveolar expansion, and nursing interventions designed to optimize lung volumes and gas exchange.
Choice A rationale
Incentive spirometry promotes deep breathing and lung expansion, preventing alveolar collapse or atelectasis common after surgery. It encourages sustained maximal inspiration, which increases surfactant production and improves oxygenation, maintaining a normal oxygen saturation of 95 to 100 percent.
Choice B rationale
Range-of-motion exercises primarily prevent musculoskeletal stiffness and deep vein thrombosis by promoting venous return. While important for overall recovery, they do not directly expand lung tissue or prevent pulmonary secretions from accumulating in the bronchioles.
Choice C rationale
Expectorants assist in thinning mucus but do not address the primary postoperative risk of hypoventilation or lung collapse. Preventive care prioritizes mechanical expansion of the lungs over pharmacological management of secretions unless a cough is present.
Choice D rationale
Suction equipment is a reactive measure used when secretions already obstruct the airway. Preventive care focuses on proactive lung expansion techniques rather than the equipment needed for emergency or symptomatic management of existing pulmonary distress.
Correct Answer is C
Explanation
Managing electrolyte imbalances in end stage renal disease requires understanding renal excretion failures. The presence of cardiac rhythm changes indicates a life threatening emergency. Immediate intervention is necessary to remove toxins and excess ions that the kidneys cannot process.
Choice A rationale
Loop diuretics are ineffective for clients with end stage renal disease because the nephrons are no longer functional. These medications cannot induce diuresis or lower serum potassium levels when the kidneys have reached the point of failure.
Choice B rationale
Similar to other loop diuretics, furosemide relies on renal blood flow and functional kidney tissue to promote fluid and electrolyte excretion. In end stage failure, this medication will not resolve the cardiac symptoms or hyperkalemia.
Choice C rationale
This is the definitive treatment for life threatening hyperkalemia in renal failure. Dialysis rapidly removes excess potassium and metabolic waste from the blood. It corrects the electrical instability in the heart caused by the high potassium levels.
Choice D rationale
Increasing fluid intake is contraindicated in end stage renal disease due to the risk of fluid volume overload. This would exacerbate the client's condition, potentially leading to pulmonary edema, hypertension, and worsening of the cardiac strain.
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