An elderly client presents to the emergency room with a family member. The family member reports that the elderly client has been vomiting and not eating or drinking for 2 days. This morning the elderly client became confused, which is new. The nurse knows the elderly client probably has which of the following?

Delirium

New onset Alzheimer's disease

New onset Huntington's disease

New onset Parkinson's disease

Answer and Explanation

The Correct Answer is A

A. Delirium is an acute, temporary state of confusion, often caused by factors such as dehydration, infection, or metabolic disturbances. In this case, the elderly client’s confusion following vomiting and not eating or drinking for 2 days suggests that dehydration or an underlying illness is likely causing the delirium.

B. Alzheimer's disease is a progressive, degenerative condition that leads to chronic memory loss and cognitive decline. It does not typically cause sudden confusion, as seen in this case.

C. Huntington's disease is a genetic neurodegenerative disorder that causes motor dysfunction and cognitive decline. It does not present suddenly with confusion in an elderly client.

D. Parkinson's disease is a progressive neurological disorder that primarily affects motor function, causing tremors, rigidity, and bradykinesia. It does not typically present with sudden confusion or the symptoms described in this case.

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Correct Answer is C

Explanation

A. A thrombotic stroke is typically caused by a blood clot that forms in an artery supplying blood to the brain, usually due to atherosclerosis. While it is a possible cause of stroke, it is not the most likely in this patient with atrial fibrillation.

B. A cerebral aneurysm involves a weakness in the blood vessel wall that can lead to rupture and bleeding, causing a hemorrhagic stroke, but this is not the most common type of stroke in patients with atrial fibrillation.

C. Embolic stroke occurs when a clot or other debris (such as a thrombus) breaks off from a distant part of the body (like the heart in atrial fibrillation) and travels to the brain, blocking a cerebral artery. This is the most common type of stroke in patients with atrial fibrillation due to the formation of clots in the left atrium that can embolize to the brain.

D. Hemorrhagic stroke is caused by the rupture of a blood vessel in the brain, leading to bleeding. It is not the most common type of stroke in patients with atrial fibrillation, though it can occur if there is coagulopathy or anticoagulant therapy.

A. Palpebral angle rigid, right and left angles B. Patient's eyes round, regular, lively, active C. Pupils equal, round, and reactive to light and accommodation D. Pupils equilateral, regular, round, little accommodation

Correct Answer is C

Explanation

A. Palpebral angle rigid, right and left angles is not a part of the PERRLA assessment. The term refers to the space between the eyelids, which is not assessed with the PERRLA acronym.

B. Patient's eyes round, regular, lively, active is a description of the general appearance of the eyes but does not correspond to the PERRLA acronym, which specifically addresses the pupils' response to light and accommodation.

C. PERRLA stands for Pupils Equal, Round, and Reactive to Light and Accommodation. This means the pupils should be equal in size, round in shape, react to light (constricting when exposed to light), and accommodate (adjust) when focusing on near or far objects. This is a standard neurological assessment used to evaluate the functioning of the eyes and the nervous system.

D. Pupils equilateral, regular, round, little accommodation does not accurately describe PERRLA. The correct term is "accommodation," which refers to the pupils' ability to adjust when focusing on near or far objects, not "little accommodation."

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Naxlex Comprehensive Predictor Exams

A post myocardial infarction patient experiences atrial fibrillation is most at risk for which type of stroke?

Correct Answer is C

Explanation

The nurse performs a visual assessment on a patient and documents the findings using the acronym PERRLA. Which assessment finding does PERRLA indicate?

Correct Answer is C

Explanation

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