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","C","D"]
Explanation
Choice A rationale
Hyponatremia, or low sodium levels, is not typically a symptom of degenerative disc disease. It can be caused by a variety of conditions, but it is not directly linked to degenerative disc disease.
Choice B rationale
Paresthesia, or abnormal sensations such as tingling or prickling, can develop with degenerative disc disease. This is due to the fact that degenerative changes can lead to nerve compression, which can cause these sensations.
Choice C rationale
Foot drop, a gait abnormality, can be a symptom of degenerative disc disease. It can occur if the disease process affects the nerves that control the muscles involved in lifting the foot.
Choice D rationale
Intermittent pain is a common symptom of degenerative disc disease. The pain can vary in intensity and may be worse with certain activities or positions.
Choice E rationale
Hyperreflexia, or overactive reflexes, is not typically a symptom of degenerative disc disease. It is more commonly associated with conditions that affect the upper motor neurons.
Correct Answer is D
Explanation
Choice A rationale
While a CT angiogram can indeed reveal fractures within the skull or spine, this is not its primary purpose in the context of a subarachnoid hemorrhage. The main goal is to visualize the blood vessels in the brain.
Choice B rationale
A CT angiogram does not primarily reveal overproduction of cerebrospinal fluid (CSF). It is used to visualize the blood vessels in the brain.
Choice C rationale
While a CT angiogram can show areas of edema within the brain tissue, this is not its main purpose in the context of a subarachnoid hemorrhage. The primary goal is to visualize the blood vessels in the brain.
Choice D rationale
A CT angiogram can indeed reveal decreased blood flow related to vasospasm in the context of a subarachnoid hemorrhage. Vasospasm is a condition in which blood vessels spasm, leading to vasoconstriction. This can reduce blood flow to the brain, which can be visualized on a CT angiogram.
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