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 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.
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.
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