A client is brought to the ED by family after falling off the roof. The care team suspects an epidural hematoma, prompting the nurse to anticipate which priority intervention?

Treatment with antihypertensive

Administration of anticoagulant therapy

Insertion of an intracranial monitoring device

Making openings in the skull (burr holes)

Answer and Explanation

The Correct Answer is D

Reasoning:

Choice A reason: Antihypertensive treatment is not the priority for epidural hematoma, which causes rapid neurological deterioration from arterial bleeding and increased ICP. While hypertension may occur, surgical evacuation via burr holes is urgent to relieve pressure and prevent brain herniation, taking precedence over blood pressure management.

Choice B reason: Anticoagulant therapy is contraindicated in epidural hematoma, as it worsens bleeding. Epidural hematomas involve arterial hemorrhage, often from trauma, and anticoagulation would increase hematoma size, exacerbating ICP and neurological damage, making this an inappropriate and harmful intervention.

Choice C reason: Inserting an intracranial monitoring device may assess ICP but is not the priority in epidural hematoma. Rapid surgical intervention (burr holes) is needed to evacuate the hematoma and relieve life-threatening pressure, as monitoring delays critical treatment in this rapidly progressing condition.

Choice D reason: Burr holes are the priority intervention for epidural hematoma, a surgical emergency caused by arterial bleeding, often from skull trauma. Rapid evacuation of the hematoma relieves increased ICP, preventing brain herniation and death, making this the most urgent and effective treatment to stabilize the client.

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Correct Answer is C

Explanation

Reasoning:

Choice A reason: Recent blood donation is not a primary cause of secondary polycythemia, which results from chronic hypoxia or erythropoietin excess, not blood loss. Donation may temporarily reduce red blood cell count, but it does not drive the increased erythropoiesis seen in secondary polycythemia, making it less relevant.

Choice B reason: A history of venous thromboembolism is a consequence, not a cause, of secondary polycythemia. Increased red blood cell mass elevates blood viscosity, raising clotting risk, but thromboembolism does not trigger polycythemia. The nurse should assess for underlying causes like hypoxia, not its complications.

Choice C reason: Evidence of lung disease is critical to assess, as secondary polycythemia is often caused by chronic hypoxia from conditions like chronic obstructive pulmonary disease. Low oxygen levels stimulate erythropoietin production, increasing red blood cell mass to enhance oxygen delivery, making lung disease a primary factor to evaluate.

Choice D reason: Impaired renal function is not a primary cause of secondary polycythemia. While kidneys produce erythropoietin, renal disease typically causes anemia due to reduced erythropoietin. Rarely, renal tumors may increase erythropoietin, but lung disease is a more common driver of secondary polycythemia in clinical practice.

A. 12 hours B. 9 hours C. 3 hours D. 6 hours

Correct Answer is C

Explanation

Reasoning:

Choice A reason: Initiating thrombolytic therapy within 12 hours is too late for optimal ischemic stroke outcomes. Beyond 4.5 hours, the risk of hemorrhage outweighs benefits, as ischemic tissue becomes necrotic, reducing the effectiveness of thrombolytics like tPA in restoring blood flow and improving function.

Choice B reason: A 9-hour window for thrombolytic therapy exceeds the recommended time frame for ischemic stroke. After 4.5 hours, the risk of hemorrhagic transformation increases, and neuronal salvage is less likely due to prolonged ischemia, making this time frame ineffective for achieving optimal functional recovery.

Choice C reason: Thrombolytic therapy within 3 hours of ischemic stroke onset maximizes functional outcomes. Tissue plasminogen activator (tPA) dissolves clots, restoring blood flow to viable brain tissue. Early administration minimizes neuronal damage, reduces disability, and improves recovery, with guidelines supporting a 3–4.5-hour window for eligible patients.

Choice D reason: A 6-hour window for thrombolytics is beyond the optimal 3–4.5-hour period for ischemic stroke. While some patients may benefit up to 4.5 hours, delays increase hemorrhage risk and reduce the likelihood of salvaging ischemic tissue, leading to poorer functional outcomes compared to earlier intervention.

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A client is brought to the ED by family after falling off the roof. The care team suspects an epidural hematoma, prompting the nurse to anticipate which priority intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client's electronic health record notes that the client has previously undergone treatment for secondary polycythemia. The nurse should assess for which factor?

Correct Answer is C

Explanation

Thrombolytic therapy should be initiated within what time frame of an ischemic stroke to achieve the best functional outcome?

Correct Answer is C

Explanation

What interventions can the nurse encourage the client with diabetes insipidus to implement to control thirst and compensate for urine loss?

Which outcome indicates that treatment of a client with diabetes insipidus has been effective?

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A client with sickle cell anemia has a:

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