A 76-year-old woman arrives at the emergency department by ambulance with a possible stroke. Vital signs are pulse 90, blood pressure 150/100, respirations 20. Thirty minutes later, vital signs are pulse 78, blood pressure 170/90, respirations 24 and irregular. The nurse should take which action at this time?

Check the client's phenytoin (Dilantin) level.

Get an order to decrease the rate of IV fluids.

Ask the woman to describe how she's feeling.

Offer the client clear liquids to prevent dehydration.

Answer and Explanation

The Correct Answer is C

A. Check the client's phenytoin (Dilantin) level: Checking the phenytoin level would not be relevant in this situation as the client's presentation suggests a possible stroke, not related to phenytoin therapy.

B. Get an order to decrease the rate of IV fluids: While managing fluid balance is important, there is insufficient information to warrant decreasing IV fluids at this time. It's essential to assess the client's overall condition and consult with the healthcare provider before making changes to IV fluid administration.

C. Ask the woman to describe how she's feeling: Assessing the client's symptoms and response to treatment is crucial for monitoring her condition and guiding further interventions, especially in
the context of a possible stroke.

D. Offer the client clear liquids to prevent dehydration: While maintaining hydration is
important, offering clear liquids would not address the potential stroke or irregular respirations. Assessment and intervention related to the client's neurological status and respiratory function take precedence.

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Correct Answer is ["B","D"]

Explanation

A. Slurred speech is often an early sign of increased ICP due to focal brain injury affecting speech areas.
B. Bradycardia is a late sign of increased ICP and is part of Cushing's triad, which includes bradycardia, irregular respirations, and widened pulse pressure
C. Hypotension is not typically associated with increased ICP; in fact, hypertension may occur as the body attempts to maintain cerebral perfusion.
D. Nonreactive dilated pupils are a late sign of increased ICP, indicating potential compression of the third cranial nerve due to brain herniation.
E. Confusion can be an early or late sign of increased ICP, but it is not specific enough to be considered a definitive late sign without other context.

A. Furnish restraints at the bedside. B. Keep an oxygen setup at the bedside. C. Place the bed in the lowest position. D. Provide a suction setup at the bedside. E. Elevate the side rails near the head when the client is in bed.

Correct Answer is ["B","D"]

Explanation

A. Furnish restraints at the bedside: Restraints are not indicated for clients with seizure disorders. In fact, restraints can increase the risk of injury during a seizure and should be avoided.

B. Keep an oxygen setup at the bedside: Oxygen may be necessary to support the client's respiratory function during and after a seizure. Having an oxygen setup readily available can ensure prompt administration if needed.

C. Place the bed in the lowest position: Lowering the bed can help prevent injury if the client
falls out of bed during a seizure. However, it is not always feasible or necessary to lower the bed to the lowest position, especially if the client has mobility limitations or other considerations.

D. Provide a suction setup at the bedside: Suctioning may be necessary to clear the airway and prevent aspiration if the client experiences excessive oral secretions or vomiting during or after a seizure.

E. Elevate the side rails near the head when the client is in bed: Elevating the side rails near the head can help prevent injury if the client thrashes or moves unpredictably during a seizure. However, it is essential to ensure that the client's head and neck remain adequately supported and that the side rails do not restrict access to the client during a seizure.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which of the following findings should the nurse identify as a late sign of ICP? (Select all that apply.)

Correct Answer is ["B","D"]

Explanation

A nurse is creating a plan of care for a client who has a history of tonic-clonic seizure disorder. Which of the following interventions should the nurse include? (Select all that apply.)

Correct Answer is ["B","D"]

Explanation

A high school teacher who has been diagnosed with epilepsy after having a generalized tonic- clonic seizure tells the nurse, "I cannot teach anymore. It will be too upsetting if I have a seizure at work." How should the nurse respond to specifically address the patient's concern?

Which information about a patient who has a new prescription for phenytoin (Dilantin) indicates that the nurse should consult with the health care provider before administration of the medication?

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?

Which of the following should be the highest priority of education plan for a client being treated with medication therapy for a generalized seizure disorder?

Which information about the patient who had a subarachnoid hemorrhage is most important to communicate to the health care provider?

A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability?

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?