A patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving a prescribed dose of aspirin?

The patient has dysphasia.

The patient has atrial fibrillation.

The patient has a history of brief episodes of right-sided hemiplegia.

The patient reports that symptoms began with a severe headache.

Answer and Explanation

The Correct Answer is D

A. The patient has dysphasia: Dysphasia (difficulty with speech) is a common symptom of stroke but does not contraindicate the use of aspirin for acute ischemic stroke management. Aspirin is routinely administered in the acute phase of ischemic stroke to prevent further clot formation.

B. The patient has atrial fibrillation: Atrial fibrillation increases the risk of embolic strokes, and aspirin may be used for stroke prevention in certain cases. However, the presence of atrial fibrillation alone does not indicate a contraindication to aspirin administration in the acute setting of a suspected stroke.

C. The patient has a history of brief episodes of right-sided hemiplegia: A history of transient ischemic attacks (TIAs) or brief episodes of hemiplegia suggests a risk factor for stroke but does not necessarily contraindicate the use of aspirin in the acute phase of stroke
management. Aspirin is commonly used for secondary prevention after TIAs or minor strokes.

D. The patient reports that symptoms began with a severe headache: Severe headache as the initial symptom of stroke raises concerns about a possible hemorrhagic stroke rather than an ischemic stroke. Administration of aspirin in the setting of a hemorrhagic stroke can worsen bleeding and increase morbidity and mortality. Therefore, the nurse should consult with the healthcare provider before giving aspirin to determine the appropriate course of action based on the patient's presentation and diagnostic evaluation.

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Correct Answer is C

Explanation

A. Check the client's phenytoin (Dilantin) level: Checking the phenytoin level would not be relevant in this situation as the client's presentation suggests a possible stroke, not related to phenytoin therapy.

B. Get an order to decrease the rate of IV fluids: While managing fluid balance is important, there is insufficient information to warrant decreasing IV fluids at this time. It's essential to assess the client's overall condition and consult with the healthcare provider before making changes to IV fluid administration.

C. Ask the woman to describe how she's feeling: Assessing the client's symptoms and response to treatment is crucial for monitoring her condition and guiding further interventions, especially in
the context of a possible stroke.

D. Offer the client clear liquids to prevent dehydration: While maintaining hydration is
important, offering clear liquids would not address the potential stroke or irregular respirations. Assessment and intervention related to the client's neurological status and respiratory function take precedence.

A. Turn the client's head to the side. B. Loosen the clothing around the client's waist. C. Document the time the seizure began. D. Check the client's motor strength.

Correct Answer is A

Explanation

A. Turn the client's head to the side: This action helps prevent aspiration by allowing any oral secretions or vomitus to drain out of the mouth, reducing the risk of airway obstruction and aspiration pneumonia.

B. Loosen the clothing around the client's waist: While it's important to ensure the client's safety during a seizure, addressing airway protection takes precedence over loosening clothing. Loosening clothing can be done after ensuring airway patency.

C. Document the time the seizure began: Documenting the time of onset is important for accurately assessing the duration of the seizure, but it is not the first action to take during an active seizure.

D. Check the client's motor strength: Assessing motor strength is important for evaluating the
client's condition after the seizure has ended, but it is not the first action to take during an active seizure. Ensuring airway protection and preventing injury are the priorities during the seizure.

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A patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving a prescribed dose of aspirin?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

Which information about a patient who has a new prescription for phenytoin (Dilantin) indicates that the nurse should consult with the health care provider before administration of the medication?

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?

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A nurse is creating a plan of care for a client who has a history of tonic-clonic seizure disorder. Which of the following interventions should the nurse include? (Select all that apply.)

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