A nurse is caring for a 77-year-old African American male client in the emergency department.
Based on the clients progression. Which of the following actions should the nurse take? Select all that apply:
The nurse should prepare to administer tPA.
The nurse should position the client on his right side.
The nurse should prepare to administer a bolus of 50% dextrose.
The nurse should anticipate the need for endotracheal intubation.
The nurse should prepare to administer antihypertensive medication
The nurse should use a calm and reassuring approach when interacting with the client.
The nurse should restrict all fluids and sodium intake.
Correct Answer : A,D,E,F
Choice A rationale: The nurse should prepare to administer tissue plasminogen activator (tPA). This medication is used to dissolve blood clots that have formed in the blood vessels of the brain. The client’s CT scan shows a large area of decreased attenuation in the left hemisphere, which is indicative of a stroke. The administration of tPA is time-sensitive and should be initiated as soon as possible after the onset of symptoms if there is no evidence of hemorrhage on the CT scan.
Choice B rationale: Positioning the client on his right side is not necessarily beneficial in this situation. The client is experiencing symptoms of a stroke, and positioning will not alleviate these symptoms. It is more important to focus on interventions that can potentially reverse the effects of the stroke, such as the administration of tPA.
Choice C rationale: There is no indication that the client requires a bolus of 50% dextrose. The client’s blood glucose levels are within normal limits, and hypoglycemia is not a concern at this time. Administering a bolus of 50% dextrose without indication could potentially lead to hyperglycemia.
Choice D rationale: The nurse should anticipate the need for endotracheal intubation. The client’s condition is deteriorating, and he is now unresponsive to verbal stimuli and only responds to painful stimuli. This indicates a decreased level of consciousness, which can compromise the client’s airway. Endotracheal intubation may be necessary to protect the client’s airway and ensure adequate ventilation.
Choice E rationale: The nurse should prepare to administer antihypertensive medication. The client’s blood pressure is significantly elevated, which can further exacerbate the damage caused by a stroke. Antihypertensive medication can help to lower the client’s blood pressure and reduce the risk of further complications.
Choice F rationale: The nurse should use a calm and reassuring approach when interacting with the client. This can help to reduce anxiety and promote a sense of safety. It is important to remember that the client may be scared and confused due to his symptoms, and a calm and reassuring approach can help to alleviate these feelings.
Choice G rationale: Restricting all fluids and sodium intake is not indicated in this situation. While fluid and sodium balance is important in stroke patients, there is no indication that the client is fluid overloaded or has a condition that would require sodium restriction. Furthermore, the client has been prescribed IV fluids, indicating that fluid restriction is not appropriate at this time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While a stiff neck can be a symptom of a cerebral aneurysm, it is not a definitive sign. A stiff neck is more commonly associated with conditions like meningitis.
Choice B rationale
Most cerebral aneurysms do not cause symptoms until they rupture or become very large. Therefore, a person with a cerebral aneurysm typically will have no symptoms.
Choice C rationale
Seizures can occur if a cerebral aneurysm ruptures and causes bleeding in the brain. However, seizures are not a common symptom of unruptured cerebral aneurysms.
Choice D rationale
Nausea and vomiting can occur if a cerebral aneurysm ruptures and causes a sudden increase in intracranial pressure. However, these are not typical symptoms of an unruptured cerebral aneurysm.
Correct Answer is A
Explanation
Choice A rationale
A traumatic brain injury (TBI) can indeed disrupt cellular function and cause blood vessel damage. This can lead to a range of potential effects, from temporary changes in brain function to long-term complications or even death.
Choice B rationale
Damage to brain tissue from decreased pressure shock waves is not typically associated with TBI. This type of injury is more commonly associated with blast injuries, such as those caused by explosions.
Choice C rationale
While increased blood supply and edema (swelling) can occur in the area of a brain injury, they are typically responses to the injury rather than direct consequences of the TBI itself. These processes can contribute to further damage and complications.
Choice D rationale
A TBI does not typically lead to increased synaptic connections. In fact, the injury can cause loss of neurons and synapses, which can lead to long-term cognitive and functional impairments.
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