A client diagnosed with a stroke complains of a severe headache. Which intervention would be the nursing priority?

Prepare for a STAT computed topography scan (CT)

Obtain a 12 lead electrocardiogram

Start an intravenous infusion of D5W at 100 mL/hr

Administer a nonnarcotic analgesics

Answer and Explanation

The Correct Answer is A

A) Prepare for a STAT computed tomography (CT) scan:
A severe headache in a client with a suspected stroke could be indicative of increased intracranial pressure (ICP), a hemorrhagic stroke, or another serious complication like cerebral edema. The priority intervention is to perform a CT scan to determine whether the stroke is ischemic (caused by a blockage) or hemorrhagic (caused by bleeding). This is crucial because the treatment approach for these two types of strokes differs significantly. For example, hemorrhagic strokes require immediate management to control bleeding and reduce ICP, whereas ischemic strokes may be treated with thrombolytics or other interventions. Therefore, preparing for a CT scan is the most urgent action to accurately diagnose the type of stroke and guide treatment decisions.

B) Obtain a 12-lead electrocardiogram (ECG):
While an ECG may be useful in assessing the cardiac rhythm and identifying potential arrhythmias (which can contribute to stroke risk), it is not the priority intervention in a patient with a suspected stroke and severe headache. The primary concern is to identify the type of stroke (ischemic or hemorrhagic), and a CT scan is the most direct way to do this. A 12-lead ECG can be obtained later if cardiac issues are suspected after stroke diagnosis.

C) Start an intravenous infusion of D5W at 100 mL/hr:
Starting an IV infusion of D5W (5% dextrose in water) is not an appropriate priority for a patient with a severe headache and suspected stroke. In fact, administering dextrose solutions may worsen the patient's condition in the case of a hemorrhagic stroke, as it could exacerbate cerebral edema or increase intracranial pressure. Fluid management in stroke patients should be approached cautiously, and IV fluids should be tailored to the patient's specific needs. The focus should be on imaging to determine the type of stroke before initiating interventions like IV fluids.

D) Administer a nonnarcotic analgesic:
While pain relief is important, administering a nonnarcotic analgesic (such as acetaminophen or ibuprofen) is not the priority in this situation. The patient's severe headache could be a sign of a serious complication like increased ICP or hemorrhagic stroke, which requires immediate diagnostic workup, not just pain management. Administering pain medication without understanding the underlying cause of the headache could mask symptoms and delay critical treatment.

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Correct Answer is D

Explanation

A) Isolate away from the family in a separate room:
Isolation is unnecessary for a client with HIV. HIV is primarily transmitted through specific bodily fluids such as blood, semen, vaginal fluids, and breast milk. The virus is not transmitted through casual contact, so there is no need for the client to isolate from their family.

B) Retest for opportunistic infections monthly:
While it is important for clients with HIV to be regularly monitored for opportunistic infections, monthly testing is not typically necessary unless specific symptoms or clinical indicators warrant it. Routine follow-up with a healthcare provider to monitor CD4 count, viral load, and overall health status is essential, but frequent opportunistic infection screening is not a general requirement.

C) Live alone to prevent any transmission of HIV:
There is no need for individuals with HIV to live alone to prevent transmission. As mentioned earlier, HIV is not spread through casual contact, so the client can live with family members without concern, as long as they follow proper precautions regarding handling blood or bodily fluids.

D) Clean any of their blood that spills with bleach:
Blood and other bodily fluids containing HIV are the primary sources of transmission. If any blood spills, cleaning the area with bleach (a disinfectant known to destroy HIV) is an important safety measure to reduce the risk of transmission. The client should also be taught to use gloves when cleaning blood spills, and to follow universal precautions when handling items contaminated with blood or other potentially infectious fluids.

A. Assess lung sounds and respiratory rate at least every 2 hours B. Assess and document pain level once every shift C. Maintain sequential compression device (SCD's) while in bed D. Elevate the head of the bed ten degrees

Correct Answer is A

Explanation

A) Assess lung sounds and respiratory rate at least every 2 hours:
In a patient with Myasthenia Gravis (MG) who has undergone thymectomy, monitoring respiratory status is critical. MG is a neuromuscular disorder that can lead to respiratory muscle weakness, which may be exacerbated post-operatively. Assessing lung sounds and respiratory rate at least every 2 hours is crucial to detect early signs of respiratory compromise, including hypoventilation or atelectasis.

B) Assess and document pain level once every shift:
While pain assessment is important, especially after a thymectomy, this action alone does not directly address the immediate issue of ineffective breathing patterns. In patients with MG, respiratory complications are a priority concern. Pain management should be part of the overall plan of care, but it is secondary to monitoring respiratory function in the acute post-operative period. Pain can affect respiratory effort, but it should be managed in the context of more pressing issues like airway and breathing assessment.

C) Maintain sequential compression device (SCD's) while in bed:
While SCDs are important in preventing deep vein thrombosis (DVT) in patients who are immobile, they are not the most appropriate intervention for a client with ineffective breathing patterns. The primary concern in a post-thymectomy patient with MG is respiratory function.

D) Elevate the head of the bed ten degrees:
While elevating the head of the bed can help with comfort and potentially improve ventilation in some patients, it is not the most specific or effective intervention for managing ineffective breathing patterns in a patient with MG. For optimal respiratory function, it is typically more beneficial to elevate the head of the bed to a higher degree (e.g., 30-45 degrees) to enhance lung expansion, rather than just 10 degrees.

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A client diagnosed with a stroke complains of a severe headache. Which intervention would be the nursing priority?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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