The nurse is assessing a patient with a suspected stroke. What assessment finding is most suggestive of a stroke?

Facial droop

Dysrhythmias

Periorbital edema

Projectile vomiting .

Answer and Explanation

The Correct Answer is A

Choice A rationale

Facial droop is a classic symptom of stroke. It occurs when there’s weakness or paralysis on one side of the face, which is caused by a disruption in the nerve signals due to a stroke. This can be easily observed in the person’s smile, as it will appear uneven.
Choice B rationale
While dysrhythmias can be associated with stroke, they are not the most indicative symptom. Dysrhythmias are more commonly associated with heart conditions.
Choice C rationale
Periorbital edema, or swelling around the eyes, is not typically a symptom of stroke. It can be caused by various conditions such as allergies, infections, or kidney problems.
Choice D rationale
Projectile vomiting is not typically a symptom of stroke. It can be caused by various conditions such as gastrointestinal issues, brain tumors, or increased intracranial pressure.

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Correct Answer is A

Explanation

Choice A rationale
Status epilepticus is a medical emergency characterized by continuous or rapid-fire seizures. Intravenous diazepam is one of the first-line treatments for this condition. It works by enhancing the effect of gamma-aminobutyric acid (GABA), a neurotransmitter that inhibits brain activity, thereby helping to stop the seizure.
Choice B rationale
Oral lorazepam is not typically used to halt a seizure immediately due to its slower onset of action compared to intravenous administration.
Choice C rationale
Oral phenytoin is not typically used to halt a seizure immediately. It is more commonly used for the long-term management of seizures.
Choice D rationale
Intravenous phenobarbital is a second-line treatment for status epilepticus, used when first- line treatments such as diazepam are ineffective.

A. Have the patient lie flat for 6 hours. B. Have the patient lie in a semi-Fowler’s position with the head of the bed at 35 degrees. C. Early ambulation. D. Have the patient lie flat for 1 hour, then sit up for 1 hour before ambulating.

Correct Answer is A

Explanation

Choice A rationale
After a lumbar puncture, it is important for the patient to lie flat for approximately 6 hours. This position helps to prevent headaches that can occur after the procedure, which are caused by leakage of cerebrospinal fluid at the needle puncture site. Lying flat allows the puncture site to seal and prevents the leakage of cerebrospinal fluid.
Choice B rationale
Having the patient lie in a semi-Fowler’s position with the head of the bed at 35 degrees is not typically recommended immediately after a lumbar puncture. This position could potentially increase the risk of a post-lumbar puncture headache.
Choice C rationale
Early ambulation is not recommended after a lumbar puncture. Moving around too soon after the procedure can increase the risk of a headache and may also increase the risk of complications at the puncture site.
Choice D rationale
Having the patient lie flat for 1 hour, then sit up for 1 hour before ambulating is not a typical recommendation after a lumbar puncture. The standard recommendation is to have the patient lie flat for approximately 6 hours to reduce the risk of complications.

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The nurse is assessing a patient with a suspected stroke. What assessment finding is most suggestive of a stroke?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who is in status epilepticus. What medication should the nurse anticipate administering to halt the seizure immediately?

Correct Answer is A

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Correct Answer is A

Explanation

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