A nurse is planning care for several clients and is considering the clients' risk for stroke. Which of the following conditions places the client at risk for an ischemic embolic stroke?

A client who has an arteriovenous malformation

A client who has thrombocytopenia

A client who has chronic atrial fibrillation

A client who has uncontrolled hypertension

Answer and Explanation

The Correct Answer is C

A client who has chronic atrial fibrillation is at risk for an ischemic embolic stroke. An ischemic embolic stroke occurs when a blood clot that forms in one part of the body travels to the brain and blocks blood ﬂow. Atrial fibrillation is a type of irregular heart rhythm that can cause blood to pool, thicken, and clot in the heart or arteries near it. Pieces of these clots can travel to the brain and cause an ischemic embolic stroke.

a. A client who has an arteriovenous malformation is not at risk for an ischemic embolic stroke.
b. A client who has thrombocytopenia is not at risk for an ischemic embolic stroke.
d. A client who has uncontrolled hypertension is at risk for a stroke but not specifically an ischemic embolic
stroke.

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Correct Answer is B

Explanation

If a client reports skin irritation around the upper edge of a lower-leg cast, the nurse should petal the edges of the cast. This involves applying adhesive strips or moleskin around the edges of the cast to smooth them out and prevent them from rubbing against the skin.

a. Suggesting that the client use a blunt object such as a comb to relieve the itch is not recommended as it can cause further irritation or damage to the skin.
c. Telling the client to apply lotion to the irritated skin is not recommended as it can cause further irritation or damage to the skin and may also damage the cast.
d. Bivalving the cast is not necessary for skin irritation around the upper edge of the cast. Bivalving involves cutting the cast in half to relieve pressure and is typically only done in cases of severe swelling or compartment syndrome.

A. The client requires total nursing care. B. The client is in a deep coma. C. The client is alert and oriented. D. The client has a stable neurological status.

Correct Answer is A

Explanation

a.A GCS score of 8 indicates severe impairment, suggesting the client may be in a state where they cannot perform basic self-care activities and thus require total nursing care.

b.A GCS score of 8 indicates severe impairment but not necessarily a deep coma. Scores below 8 suggest a comatose state, but deep coma is more likely to be indicated by a score of 3-4.

c.A GCS score of 8 is not consistent with a client who is alert and oriented. This score indicates significant neurological impairment.

d.A GCS score of 8 does not indicate stable neurological status. It suggests severe impairment and potentially unstable or deteriorating neurological condition.

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A nurse is planning care for several clients and is considering the clients' risk for stroke. Which of the following conditions places the client at risk for an ischemic embolic stroke?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has a lower-leg cast reports skin irritation around the upper edge of the cast. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is collecting data from a client who has a score of 8 using the Glasgow Coma Scale. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is collecting data from a client following the application of a leg cast for the treatment of a fracture. Which of the following findings should the nurse expect to find first if the cast is too tight?

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