The nurse is performing a neurologic assessment on a client admitted for possible stroke.
Which technique should the nurse adopt to ensure an accurate assessment?

Perform testing rapidly so stroke treatment is not delayed.

Place the client in the supine position.

Compare the exam from one side of the body to the other.

Administer an anxiolytic before the assessment.

Answer and Explanation

The Correct Answer is C

Accurate neurologic assessment in suspected stroke requires systematic comparison to identify focal deficits. Applying knowledge of neuroanatomy and lateralization of brain function is essential to differentiate between localized ischemic events and generalized systemic issues, ensuring the correct vascular territory is identified.

Choice A rationale

Rapid assessments may lead to overlooking subtle focal neurologic deficits or sensory changes. Precision is required to localize the brain lesion accurately. While time is critical in stroke, haste must not compromise the integrity and detail of the examination.

Choice B rationale

The supine position may increase intracranial pressure or compromise the airway in a stroke patient with decreased gag reflexes. Assessing certain reflexes and motor strength often requires varying the head of the bed to at least 30 degrees for safety.

Choice C rationale

Symmetry is the hallmark of neurologic health. Comparing left and right sides allows the nurse to identify unilateral weakness, sensory loss, or reflex changes characteristic of stroke. This lateralization helps distinguish focal neurological deficits from global brain dysfunction.

Choice D rationale

Anxiolytics can depress the central nervous system, altering the level of consciousness and pupillary responses. This medication masks the client's true neurologic status, making it impossible to obtain a baseline or detect subtle clinical changes or deterioration.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Disseminated intravascular coagulation is a complex secondary complication of sepsis. Knowledge of the coagulation cascade, specifically the paradoxical relationship between widespread microvascular clotting and systemic hemorrhage due to the depletion of clotting factors and fibrinogen, is necessary to explain this condition.

Choice A rationale

DIC begins with excessive thrombin generation, leading to widespread fibrin deposition in the microcirculation. This process consumes clotting factors and fibrinogen, eventually resulting in severe bleeding. It is a disorder characterized by abnormal, systemic activation of coagulation.

Choice B rationale

DIC is characterized by a decreased platelet count, not an elevated one. Platelets are consumed rapidly as they form numerous small clots throughout the body. Thrombocytopenia is a hallmark laboratory finding used to diagnose this life-threatening condition.

Choice C rationale

DIC is an acute, life-threatening complication, not a chronic condition requiring lifelong heparin. While heparin may be used in specific phases to stop the clotting cascade, the primary treatment focuses on resolving the underlying cause, such as sepsis.

Choice D rationale

DIC is an acquired syndrome, not a genetic disorder. While vitamin K is essential for the synthesis of certain clotting factors, the primary pathology of DIC involves the overstimulation of the clotting cascade rather than a simple deficiency.

Correct Answer is ["10"]

Explanation

Step 1 is 1 mg ÷ (0.1 mg ÷ 1 mL).

Step 2 is 1 mg ÷ 0.1 mg/mL = 10 mL. Final answer is 10 mL..

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The nurse is performing a neurologic assessment on a client admitted for possible stroke. Which technique should the nurse adopt to ensure an accurate assessment?

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Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?

Correct Answer is A

Explanation

Correct Answer is ["10"]

Explanation

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The nurse is performing a neurologic assessment on a client admitted for possible stroke.
Which technique should the nurse adopt to ensure an accurate assessment?