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 ["24"]
Explanation
- Step 1: Identify the prescribed dose in units per hour. The client is scheduled to receive 1,200 units/hr of heparin.
- Step 2: Identify the concentration of the available solution. The available solution contains 25,000 units of heparin in 500 mL D5W.
- Step 3: Calculate the volume of solution needed to deliver the required dose. We can set up a proportion to solve for this:
- 25,000 units is to 500 mL as 1,200 units is to X mL.
- In other words, 25,000 units : 500 mL = 1,200 units : X mL.
- Step 4: Solve for X using cross-multiplication and division:
- Cross-multiplication gives us: 25,000 units × X mL = 1,200 units × 500 mL.
- Simplifying this gives us: 25,000X = 600,000.
- Dividing both sides by 25,000 gives us: X = 600,000 ÷ 25,000.
- Calculating the division gives us: X = 24.
Set the IV pump to deliver 24 mL/hr to administer the required dose of 1,200 units/hr.
Correct Answer is ["0.2"]
Explanation
- Step 1: Identify the required dose in milligrams (mg). The nurse is scheduled to administer 2 mg of morphine sulfate.
- Step 2: Identify the concentration of the available solution. The available solution contains 10 mg of morphine sulfate per 1 mL.
- Step 3: Calculate the volume of solution needed to deliver the required dose. We can set up a proportion to solve for this:
- 10 mg is to 1 mL as 2 mg is to X mL.
- In other words, 10 mg : 1 mL = 2 mg : X mL.
- Step 4: Solve for X using cross-multiplication and division:
- Cross-multiplication gives us: 10 mg × X mL = 2 mg × 1 mL.
- Simplifying this gives us: 10X = 2.
- Dividing both sides by 10 gives us: X = 2 ÷ 10.
- Calculating the division gives us: X = 0.2.
So, the nurse should administer 0.2 mL of the morphine sulfate solution per dose.
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