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:Placing a cool cloth on the forehead may provide comfort but does not address intracranial pressure, which could be causing the headache[^10^].

Choice B reason:Elevating the head of the bed 30 degrees helps to decrease intracranial pressure and can alleviate headache symptoms associated with a closed head injury[^10^].

Choice C reason:Administering morphine for pain relief should be done with caution, as it can depress respiration and mask changes in the level of consciousness, which are important indicators of neurological status[^10^].

Choice D reason:A lumbar puncture is contraindicated in the presence of increased intracranial pressure due to the risk of brain herniation[^10^].

A. Profuse vomiting with fecal odor B. Epigastric abdominal distention C. Intermittent abdominal cramping D. Ribbon-like stools or diarrhea E. Metabolic acidosis F. Severe fluid and electrolyte imbalance

Correct Answer is ["A","B","C","D","E","F"]

Explanation

Choice A reason:Profuse vomiting with a fecal odor can occur in large bowel obstructions due to the backward flow of bowel contents.

Choice B reason:Epigastric abdominal distention is a common finding in bowel obstructions due to the accumulation of gas and fluids.

Choice C reason:Intermittent abdominal cramping results from the bowel's attempt to push contents through the obstructed area.

Choice D reason:Ribbon-like stools or diarrhea may occur if there is a partial obstruction allowing some contents to pass.

Choice E reason:Metabolic acidosis can develop due to the accumulation of lactic acid from tissue hypoxia and decreased perfusion.

Choice F reason:Severe fluid and electrolyte imbalance can result from vomiting and the inability to absorb fluids and nutrients properly.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

A client presents with a possible bowel obstruction, and the nurse completes a detailed abdominal assessment. Which of the following clinical manifestations are consistent with a large bowel obstruction? (Select all that apply).

Correct Answer is ["A","B","C","D","E","F"]

Explanation

A nurse is assessing a client who has left-sided heart failure. Which of the following clinical manifestations will the nurse expect?

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