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 A
Explanation
The nurse should explain that cardiac enzyme studies measure the levels of certain enzymes, such as troponin, creatine kinase, and lactate dehydrogenase, that are released into the bloodstream when the heart muscle is damaged by an MI. These tests help determine the degree of damage to the heart tissues, as well as the timing and severity of the MI.
"These tests will enable the provider to determine the heart structure and mobility of the heart valves." is wrong because cardiac enzyme studies do not provide information about the heart structure and mobility of the heart valves. Other tests, such as echocardiography or cardiac catheterization, may be used for this purpose.
"Cardiac enzymes will identify the location of the MI." is wrong because cardiac enzyme studies do not indicate the specific location of the MI within the heart. Other tests, such as electrocardiography or coronary angiography, may be used for this purpose.
"Cardiac enzymes assist in diagnosing the presence of pulmonary congestion." is wrong because cardiac enzyme studies do not directly assess the presence of pulmonary congestion, which is a complication of heart failure. Other signs and symptoms, such as dyspnea, crackles, and chest x-ray findings, may be used for this purpose.
Correct Answer is ["50"]
Explanation
To calculate the gt/min, the nurse should use the following formula:
gt/min = (mL/hr x drop factor) / 60
Plugging in the given values, we get:
gt/min = (150 mL/hr x 20 gt/mL) / 60
gt/min = 3000 gt/hr / 60 gt/min = 50 gt/min
Therefore, the nurse should set the manual IV infusion to deliver 50 gt/min.
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