A nurse in the emergency department is caring for a client who had a seizure and became unresponsive after stating they had a sudden, severe headache. 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 neurological disorders should the nurse suspect?

Embolic stroke

Thrombotic stroke

Transient ischemic attack (TIA)

Hemorrhagic stroke

Answer and Explanation

The Correct Answer is D

Choice A. An embolic stroke is caused by an embolus, often a blood clot, that travels to the brain from another part of the body. It does not typically present with a sudden, severe headache.

Choice B. A thrombotic stroke occurs when a blood clot forms inside one of the brain's arteries. While it can cause a headache, it is not usually characterized by a sudden, severe headache.

Choice C. A transient ischemic attack (TIA) is often called a mini-stroke and symptoms are temporary. A sudden, severe headache is more indicative of a hemorrhagic stroke.

Choice D. A hemorrhagic stroke, which involves bleeding within the brain, is most likely to cause a sudden, severe headache, and can lead to seizures and changes in consciousness.

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Correct Answer is B

Explanation

Choice A reason: A BUN level of 8 mg/dL and creatinine level of 0.7 mg/dL are within normal ranges and would not be expected in a client with CKD².

Choice B reason: Elevated BUN and creatinine levels, such as 45 mg/dL and 8 mg/dL respectively, are indicative of impaired kidney function, which is consistent with CKD².

Choice C reason: A BUN level of 10 mg/dL and creatinine level of 0.3 mg/dL are lower than the expected values for a client with CKD, indicating better kidney function than typically seen in CKD².

Choice D reason: A BUN level of 23 mg/dL and creatinine level of 1.0 mg/dL may be slightly elevated but are not as indicative of CKD as the values in choice B².

A. Sodium level B. Intake and output C. Daily weight D. Tissue turgor

Correct Answer is C

Explanation

Choice A reason: Sodium level is not a direct measure of fluid volume. While sodium balance can influence fluid status, the serum sodium level can be affected by various factors and does not reliably indicate fluid volume increase on its own.

Choice B reason: Intake and output records are important for managing fluid balance, especially in a hospital setting. However, they can be influenced by many factors, such as incomplete recording or insensible losses, and do not provide a direct measure of fluid retention.

Choice C reason: Daily weight is considered the most reliable measure of fluid retention. Weight changes can reflect fluid balance accurately because 1 liter of fluid is roughly equivalent to 1 kilogram of body weight. In clients with chronic kidney disease, daily weight monitoring can help detect fluid volume increases or decreases promptly. For a client with chronic kidney disease, daily weight monitoring is a key assessment tool for detecting fluid volume changes. It provides a quantifiable and objective measure that can guide interventions to manage fluid balance effectively.

Choice D reason: Tissue turgor, which refers to the skin’s elasticity, is not a reliable measure of fluid volume. It can be influenced by age, edema, and other factors, and changes in turgor may not accurately reflect fluid status in the body.

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Naxlex Comprehensive Predictor Exams

A nurse is reviewing the BUN and creatinine levels of an older adult client who has chronic kidney disease (CKD). Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is assessing a client who has chronic kidney disease for fluid volume increase. Which of the following provides a reliable measure of fluid retention?

Correct Answer is C

Explanation

A client who has a recent closed head injury reports a severe headache and is restless. Which of the following is an appropriate nursing intervention?

A client with advanced cirrhosis has been admitted to the medical-surgical unit. The nurse is assessing the client and identifies which of the following findings as indicators of hepatic encephalopathy? (Select all that apply).

A nurse in the emergency department is caring for a client who took three nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now is experiencing a headache. Which of the following statements should the nurse make?

The nurse is caring for a client with cirrhosis and portal hypertension. Which statement by the client is cause for the greatest concern?

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