A 21-year-old male was admitted to the emergency department following a high-speed motorcycle accident.
He was reported to be unconscious at the scene, but upon arrival he was awake and oriented with a Glasgow Coma Scale (GCS) of 15. Suddenly, he becomes unconscious and mental status deteriorates to a GCS of 8. The nurse anticipates which of the following injuries?

Subarachnoid hemorrhage.

Diffuse axonal injury.

Epidural hematoma.

Subdural hematoma.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Subarachnoid hemorrhage is less likely given the sudden decrease in consciousness. This type of injury typically results in severe headache or focal neurological deficits, not rapid mental decline.

Choice B rationale

Diffuse axonal injury usually presents with persistent unconsciousness rather than sudden deterioration. It results from widespread shearing forces and is less likely with the reported history.

Choice C rationale

Epidural hematoma often presents with a lucid interval followed by sudden neurological decline, as described in this case. Rapid accumulation of blood between the dura and skull can compress brain tissue.

Choice D rationale

Subdural hematoma tends to cause gradual neurological deterioration rather than a sudden decrease in Glasgow Coma Scale. This occurs due to slower venous bleeding. .

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Correct Answer is C

Explanation

Choice A rationale

Subarachnoid hemorrhage is less likely given the sudden decrease in consciousness. This type of injury typically results in severe headache or focal neurological deficits, not rapid mental decline.

Choice B rationale

Diffuse axonal injury usually presents with persistent unconsciousness rather than sudden deterioration. It results from widespread shearing forces and is less likely with the reported history.

Choice C rationale

Choice D rationale

Subdural hematoma tends to cause gradual neurological deterioration rather than a sudden decrease in Glasgow Coma Scale. This occurs due to slower venous bleeding. .

A. Prepare to administer recombinant tissue plasminogen activator (t-PA). B. Assist with transport to a STAT non-contrast computed tomography scan of the head. C. Perform a STAT EKG and assist with a STAT chest X-ray. D. Notify the speech and language pathologist for a STAT dysphagia evaluation.

Correct Answer is B

Explanation

Choice A rationale

Administering recombinant tissue plasminogen activator (t-PA) may be necessary, but confirming ischemic stroke via CT scan precedes treatment to rule out hemorrhagic stroke, which contraindicates t-PA.

Choice B rationale

Performing a STAT non-contrast CT scan of the head is the priority to differentiate between ischemic and hemorrhagic stroke, enabling appropriate and timely intervention.

Choice C rationale

A STAT EKG and chest X-ray, though helpful in identifying concurrent cardiac or pulmonary issues, are not immediate priorities in acute stroke evaluation.

Choice D rationale

While assessing dysphagia is critical post-stroke, it is not a priority during initial stroke evaluation, which focuses on rapid imaging and differentiation of stroke type. .

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A 78-year-old client is admitted to the Emergency Department with numbness and weakness of the right arm and slurred speech.Which nursing intervention is a priority?

Correct Answer is B

Explanation

The nurse is caring for a patient with epilepsy who has recently had a change in their prescribed medication combination.Which of the following options are priority to institute?

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The nurse is caring for a patient in the acute care setting with a spinal cord injury at the level of C-3. The nurse understands that the main cause of complications or death related to this injury includes:

The client who is diagnosed with a seizure disorder is prescribed a ketogenic diet.The nurse knows that the client understands the teaching when they state:

The nurse observes increased eye blinking and lip smacking in a client who has a history of absence seizures.The nurse is aware these symptoms indicate:

The nurse is caring for several patients in the Intensive Care Unit (ICU). Which of the following patients is at the greatest risk of anoxic brain injury?

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