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 C

Explanation

Choice A reason: Metabolic alkalosis would present with an elevated pH and HCO3, which is not the case here.

Choice B reason: Respiratory alkalosis would present with an elevated pH and a decreased PaCO2, which is not the case here.

Choice C reason: Metabolic acidosis is indicated by a decreased pH and HCO3, which aligns with the ABG findings provided.

Choice D reason: Respiratory acidosis would present with a decreased pH and an elevated PaCO2, which is not the case here.

A. Instruct the client to perform range-of-motion exercises to his lower extremities. B. Ambulate the client 1 hour following the procedure. C. Restrict the client's fluid intake. D. Assess the color, temperature, and pulse in the affected extremity.

Correct Answer is D

Explanation

Choice A reason: Instructing the client to perform range-of-motion exercises to his lower extremities immediately after cardiac catheterization is not recommended. The client should maintain bed rest with the affected leg straight to prevent bleeding from the catheter insertion site.

Choice B reason: Ambulating the client 1 hour following the procedure is not advised. After femoral artery access, the client is typically required to remain on bed rest with the affected leg straight for several hours to ensure hemostasis and prevent bleeding².

Choice C reason: Restricting the client's fluid intake is not a standard post-procedure action. Adequate hydration is important after cardiac catheterization to help flush the contrast dye used during the procedure from the body, unless contraindicated.

Choice D reason: Assessing the color, temperature, and pulse in the affected extremity is crucial for detecting signs of bleeding, hematoma formation, or arterial occlusion. These assessments should be performed regularly as part of post-cardiac catheterization care².

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Naxlex Comprehensive Predictor Exams

A nurse is reviewing a client's laboratory report of arterial blood gas (ABG) findings: pH 7.28, HCO3 18, and PaCO2 36. Which of the following conditions should the nurse anticipate when interpreting these findings?

Correct Answer is C

Explanation

A nurse is planning care for a client who has undergone cardiac catheterization through the femoral artery. Which of the following actions should the nurse plan to take?

Correct Answer is D

Explanation

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