A nurse is caring for a client who presented with unilateral facial droop and weakness that lasted for about an hour before resolving spontaneausly without intervention. Which of the following is true regarding this situation?

The blockage is most likely in the right parietal region

This type of event can be one of the primary warning sign of a future stroke

The signs and symptoms are most consistent with an acute hemorrhagic stroke

The signs and symptoms are most consistent with a focal awareness seizure.

Answer and Explanation

The Correct Answer is B

A. The blockage is most likely in the right parietal region:
While a facial droop and weakness can be indicative of a stroke, the specific location of the blockage cannot be definitively determined based on the symptoms alone. A right-sided facial droop suggests that the lesion or event likely involves the left side of the brain, particularly the frontal or temporal regions, as these areas are typically associated with facial motor control. A parietal lesion would more commonly result in sensory deficits or spatial issues, not primarily facial droop. Therefore, this statement is not correct in this case.

B. This type of event can be one of the primary warning signs of a future stroke:
The client’s presentation of unilateral facial droop and weakness that resolves spontaneously within an hour is highly consistent with a transient ischemic attack (TIA). A TIA, often referred to as a "mini-stroke," is characterized by temporary neurological deficits that resolve without permanent damage. TIAs are considered warning signs of a potential future stroke, and the client should be evaluated promptly to address risk factors and prevent a more serious, permanent stroke.

C. The signs and symptoms are most consistent with an acute hemorrhagic stroke:
An acute hemorrhagic stroke typically presents with sudden and severe neurological deficits, such as a severe headache, vomiting, and loss of consciousness. Hemorrhagic strokes do not typically resolve spontaneously within an hour. The client's symptoms (unilateral facial droop and weakness that resolve within an hour) are more indicative of a TIA, not a hemorrhagic stroke. A hemorrhagic stroke would likely result in sustained deficits and a more urgent clinical presentation.

D. The signs and symptoms are most consistent with a focal awareness seizure:
Focal awareness seizures (previously known as simple partial seizures) generally involve abnormal electrical activity in a specific area of the brain, leading to symptoms such as motor twitches or sensory disturbances, but not typically a full facial droop or weakness. These seizures do not cause symptoms that resolve in such a short time, nor do they present with unilateral weakness in the manner described here. Therefore, this scenario is not consistent with a seizure disorder.

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Correct Answer is ["2"]

Explanation

Given:

Desired dose: Dextromethorphan 30 mg PO

Available concentration: Dextromethorphan oral liquid 75 mg/5 mL

To find:

Volume to administer (in mL)

Step 1: Set up the proportion

We can use the following proportion to solve the problem:

(Desired dose) / (Available concentration) = Volume to administer

Step 2: Substitute the values

Plugging in the given values, we get:

(30 mg) / (75 mg/5 mL) = Volume to administer

Step 3: Simplify

To simplify, we can invert the denominator and multiply:

(30 mg) x (5 mL / 75 mg) = Volume to administer

The "mg" units cancel out, leaving us with:

(30 x 5 mL) / 75 = Volume to administer

Step 4: Calculate

Performing the multiplication and division, we get:

150 mL / 75 = Volume to administer

2mL = Volume to administer

A. Have the client use the call light if they need to get up B. Pad the side rails of the client’s bed C. Ensure the lights in the room are as bright as possible at all times D. Avoid over stimulation and excessive activity in the client’s room

Correct Answer is C

Explanation

A. "Have the client use the call light if they need to get up":
This is an appropriate precaution to promote safety for a patient who has seizures. It is important to encourage patients to call for assistance before getting up, especially if they are at risk for seizures. Having the patient use the call light ensures that they do not try to walk or move without supervision, which could lead to falls or injury.

B. "Pad the side rails of the client’s bed":
This is also an appropriate precaution. Padding the side rails of the bed is a common safety measure for patients who are at risk for seizures. The padding helps prevent injury if the patient moves during a seizure. Side rails should be raised during a seizure to prevent the patient from falling out of bed, but the risk of injury from the side rails themselves is minimized with padding.

C. "Ensure the lights in the room are as bright as possible at all times":
This is not an appropriate precaution. Bright lights in the room could potentially cause overstimulation, which may be a trigger for seizures in some patients. In addition, bright lights could contribute to discomfort and anxiety. Instead, the room should be kept at a comfortable, calm lighting level to help reduce stress and minimize the risk of triggering a seizure.

D. "Avoid over stimulation and excessive activity in the client’s room":
This is an appropriate precaution. Avoiding overstimulation is important for patients with seizure disorders. Excessive noise, bright lights, or other sources of stress or agitation could provoke a seizure. A calm, quiet environment helps to promote safety and reduce the risk of a seizure occurring.

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A nurse is caring for a client who presented with unilateral facial droop and weakness that lasted for about an hour before resolving spontaneausly without intervention. Which of the following is true regarding this situation?

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer dextromethorphan 30 mg PO. The amount available is dextromethorphan oral liquid 7.5 mg/5mL. How many should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero)

Correct Answer is ["2"]

Explanation

The nurse is caring for a patient who was admitted for seizures. All of the following precautions should be taken to promote a safe environment except which?

Correct Answer is C

Explanation

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