A patient arrives in the emergency department exhibiting symptoms of a cerebrovascular accident (CVA). Which diagnostic evaluations would the nurse anticipate before treatment is initiated?

Prothrombin level

Brain CT or MRI

Chest x-ray

Lumbar puncture

Answer and Explanation

The Correct Answer is B

Choice A rationale

While prothrombin level is an important test in evaluating blood clotting disorders, it is not typically used in the initial diagnostic evaluations for a cerebrovascular accident (CVA) or stroke.
Choice B rationale
Brain CT or MRI scans are commonly used in the initial diagnostic evaluations for a CVA. These imaging tests can show bleeding in the brain, an ischemic stroke, a tumor, or other conditions.
Choice C rationale
A chest x-ray is not typically used in the initial diagnostic evaluations for a CVA. It is more commonly used to diagnose conditions affecting the lungs and heart.
Choice D rationale
A lumbar puncture, or spinal tap, may be used in some cases to help diagnose a CVA, but it is not typically part of the initial diagnostic evaluations.

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Correct Answer is A

Explanation

Choice A rationale

Ascending muscle weakness is a classic symptom of Guillain-Barre syndrome. It often starts in the feet and legs before spreading to the upper body and arms.
Choice B rationale
Difficulty with urination is not a typical symptom of Guillain-Barre syndrome.
Choice C rationale
Ptosis (drooping of the upper eyelid) and diplopia (double vision) are not common symptoms of Guillain-Barre syndrome.
Choice D rationale
Ear distortion and pain are not associated with Guillain-Barre syndrome.

A. By using the Romberg test B. By assessing the patient’s sensitivity to temperature and touch C. By observing the patient’s response to painful stimuli D. By observing the reaction of pupils to light

Correct Answer is C

Explanation

Choice C rationale
When providing care for a comatose patient, a nurse should evaluate motor responses by observing the patient’s response to painful stimuli. This can be done by applying a painful stimulus, such as a trapezius pinch or nailbed pressure, and observing the patient’s motor response. Purposeful or semi-purposeful movements, such as localizing or withdrawing from pain, can provide valuable information about the patient’s level of consciousness and neurological function.
Choice A rationale
The Romberg test is used to evaluate balance and is not typically used to evaluate motor responses in a comatose patient.
Choice B rationale
Assessing the patient’s sensitivity to temperature and touch can provide information about sensory function, but it does not directly evaluate motor responses.
Choice D rationale

Observing the reaction of pupils to light can provide information about cranial nerve function, but it does not directly evaluate motor responses.

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A patient arrives in the emergency department exhibiting symptoms of a cerebrovascular accident (CVA). Which diagnostic evaluations would the nurse anticipate before treatment is initiated?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In the context of an initial assessment for a client admitted to rule out Guillain-Barre syndrome, which of the following symptoms would the nurse expect to observe?

Correct Answer is A

Explanation

When providing care for a comatose patient, how should a nurse evaluate motor responses?

Correct Answer is C

Explanation

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