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 C
Explanation
Choice A rationale
Trigeminal neuralgia is a chronic pain condition that affects the trigeminal nerve, which carries sensation from your face to your brain. It does not cause a sensation of tightness around the torso.
Choice B rationale
Lhermitte’s sign is a symptom of multiple sclerosis and other neurological conditions where a person feels an electric shock-like sensation running down the spine and into the limbs. It does not cause a sensation of tightness around the torso.
Choice C rationale
The sensation of tightness around the torso in a patient with multiple sclerosis is often referred to as the “MS hug”. It is caused by a lesion or an area of active inflammation within the spinal cord.
Choice D rationale
Paroxysmal spasms are a type of muscle spasm experienced by some people with multiple sclerosis. These spasms are usually painful and involve the muscles of the legs, but they do not cause a sensation of tightness around the torso.
Correct Answer is B
Explanation
Choice A rationale
Serotonin is indeed an inhibitory neurotransmitter. It helps regulate mood, appetite, and sleep among other things. However, its role in the nervous system is complex and it can also have excitatory effects depending on the specific receptors and neural pathways involved.
Choice B rationale
Gamma-aminobutyric acid (GABA) is the primary inhibitory neurotransmitter in the brain. It works by decreasing neuronal excitability, which helps to regulate muscle tone, among other functions.
Choice C rationale
Acetylcholine is primarily an excitatory neurotransmitter, although it can have inhibitory effects in certain parts of the nervous system. It plays a key role in muscle activation, learning, and memory.
Choice D rationale
Dopamine can act as both an inhibitory and an excitatory neurotransmitter, depending on the type of receptor it binds to and the specific neural pathway involved. It plays key roles in reward, motivation, and motor control.
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