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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["60"]
Explanation
- Step 1: Identify the required dose in grams. The client is scheduled to receive 30 grams of lactulose.
- Step 2: Identify the concentration of the available solution. The available solution contains 5 grams of lactulose per 10 mL.
- Step 3: Calculate the volume of solution needed to deliver the required dose. We can set up a proportion to solve for this:
- 5 grams is to 10 mL as 30 grams is to X mL.
- In other words, 5 g : 10 mL = 30 g : X mL.
- Step 4: Solve for X using cross-multiplication and division:
- Cross-multiplication gives us: 5 g × X mL = 30 g × 10 mL.
- Simplifying this gives us: 5X = 300.
- Dividing both sides by 5 gives us: X = 300 ÷ 5.
- Calculating the division gives us: X = 60.
60 mL of the lactulose solution should be poured into the medication cup to administer the required dose of 30 grams.
Correct Answer is A
Explanation
Choice A reason:Placing the client in a sitting position helps to lower blood pressure by promoting venous return and is the first action to take in cases of autonomic dysreflexia²³.
Choice B reason:While examining for skin breakdown is important, it is not the first action to take when autonomic dysreflexia is suspected.
Choice C reason:Checking the bladder for distention is a critical step, but it should be done after positioning the client to address immediate blood pressure concerns.
Choice D reason:Checking for fecal impaction is also important but follows the initial step of positioning the client to manage blood pressure.
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