A patient presents to the emergency department (ED) complaining of nausea, vomiting, and the “worst headache he has ever experienced.”. While examining the patient, the nurse notes left leg and arm weakness.
The patient is immediately sent to the radiology department for a CT scan.
The registered nurse (RN) identifies the immediate need for treatment because:
A hemorrhagic brain attack is more common than an ischemic brain attack.
A thrombolytic drug will cause the peripheral and central reflexes to become hyper-reactive.
A hemorrhagic brain attack requires immediate intervention to prevent further damage.
An ischemic brain attack is less severe than a hemorrhagic brain attack.
The Correct Answer is C
Choice A rationale
A hemorrhagic brain attack (stroke) is less common than an ischemic brain attack. Ischemic strokes account for the majority of strokes.
Choice B rationale
Thrombolytic drugs are used to treat ischemic strokes, not hemorrhagic strokes. They do not cause hyper-reactive reflexes.
Choice C rationale
A hemorrhagic brain attack requires immediate intervention to prevent further damage. Hemorrhagic strokes involve bleeding in the brain, which can rapidly worsen and cause severe damage.
Choice D rationale
An ischemic brain attack is not necessarily less severe than a hemorrhagic brain attack. Both types of strokes are serious, but hemorrhagic strokes often require more urgent intervention due to the risk of ongoing bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Post-renal acute kidney injury (AKI) is caused by obstruction of urine flow, leading to decreased urine output, but it does not typically cause crackles in the lungs.
Choice B rationale
Diabetes insipidus (DI) is characterized by excessive urination and thirst due to a deficiency of antidiuretic hormone (ADH), but it does not cause crackles in the lungs.
Choice C rationale
Syndrome of inappropriate antidiuretic hormone (SIADH) involves excessive release of ADH, leading to water retention and hyponatremia, but it does not cause crackles in the lungs.
Choice D rationale
Congestive heart failure (CHF) can lead to fluid accumulation in the lungs (crackles) and decreased urine output due to poor cardiac function and renal perfusion.
Correct Answer is A
Explanation
Choice A rationale
Meningitis presents with fever, stiff neck, and photophobia. It is an inflammation of the membranes surrounding the brain and spinal cord, often caused by infection.
Choice B rationale
Encephalitis involves inflammation of the brain itself, presenting with fever, headache, and altered mental status, but not specifically photophobia.
Choice C rationale
Migraine can cause photophobia and headache but is not typically associated with fever and stiff neck.
Choice D rationale
Sinusitis can cause fever and headache but not typically photophobia and stiff neck.
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