A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider?

The patient's blood pressure (BP) is 144/90 mm Hg.

The patient takes a diuretic because of a history of hypertension.

The patient has atrial fibrillation and takes warfarin (Coumadin).

The patient's speech is difficult to understand.

Answer and Explanation

The Correct Answer is C

A. The patient's blood pressure (BP) is 144/90 mm Hg: While elevated blood pressure may contribute to the risk of intracerebral hemorrhage, the patient's current BP is not excessively high and may not be the most critical factor in this situation compared to other factors such as anticoagulant use.

B. The patient takes a diuretic because of a history of hypertension: While the patient's history of hypertension and diuretic use are relevant to their overall health status, they may not be the most immediate concern in the context of intracerebral hemorrhage.

C. The patient has atrial fibrillation and takes warfarin (Coumadin): This information is crucial as it indicates that the patient is anticoagulated, which can significantly impact the severity and management of intracerebral hemorrhage. Anticoagulant use increases the risk of bleeding and can worsen outcomes in cases of intracranial hemorrhage.

D. The patient's speech is difficult to understand: While difficulty with speech may indicate neurological impairment, it is not as immediately concerning as the patient's anticoagulant use, which increases the risk of bleeding complications and may require specific interventions such as reversal agents.

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Correct Answer is B

Explanation

A. Oral Levetiracetam: Oral medications are not appropriate for immediate seizure management during an active seizure. Intravenous medications are typically used for acute seizure management.

B. IV Lorazepam: Lorazepam is a benzodiazepine that is commonly used as a first-line medication for terminating acute seizures. It acts quickly to suppress seizure activity and is often administered intravenously during a seizure episode.

C. IV Ondansetron: Ondansetron is an antiemetic medication used to prevent nausea and vomiting and is not indicated for seizure management.

D. Magnesium Sulfate: Magnesium sulfate is not typically used for seizure management in the acute setting. It may be used for certain types of seizures or as a treatment for eclampsia, but it is not a first-line medication for acute seizure termination.

A. Remove clothing B. Maintain cervical spine precaution C. Perform a mental status exam D. Assess for facial lacerations

Correct Answer is B

Explanation

A. Remove clothing: While removing clothing may be necessary for a thorough assessment and treatment, maintaining cervical spine precaution takes precedence to prevent potential spinal cord injury in clients with a history of trauma, such as a fall from a significant height.

B. Maintain cervical spine precaution: Maintaining cervical spine precaution by stabilizing the cervical spine and immobilizing the neck is crucial to prevent further injury to the spinal cord in clients with a history of trauma until spinal injury is ruled out or managed.

C. Perform a mental status exam: While assessing the client's mental status is important for evaluating neurological function, it is not the first priority in a client with potential spinal cord injury following a fall.

D. Assess for facial lacerations: Assessing for facial lacerations is important for identifying and managing potential facial injuries, but it is not the first priority in the primary assessment of a client with a history of trauma and potential spinal cord injury.

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A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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