A client is brought to the emergency department with symptoms of a cerebrovascular accident (CVA). The nurse would anticipate which diagnostic evaluation to be completed prior to initiation of treatment?
Prothrombin level
Chest x-ray
Brain CT scan or MRI
Lumbar puncture
The Correct Answer is C
A. Prothrombin level: Although checking coagulation levels like prothrombin time may be important, it is not the first-line diagnostic tool for determining the type of stroke (ischemic or hemorrhagic), which is critical for treatment decisions.
B. Chest x-ray: A chest x-ray is not directly related to diagnosing or determining the type of stroke. It may be used for other purposes, such as assessing for respiratory issues, but it is not the priority in stroke diagnosis.
C. Brain CT scan or MRI: A brain CT scan or MRI is the most crucial diagnostic test to perform before initiating treatment for a stroke. This imaging helps differentiate between ischemic and hemorrhagic stroke, guiding the appropriate treatment approach.
D. Lumbar puncture: A lumbar puncture may be used in certain neurological evaluations but is not the first-line test for diagnosing a stroke. It is invasive and not typically performed in the acute setting for stroke evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I feel like everyone depends on me too much." This statement indicates a sense of responsibility and connection to others, which may not directly indicate suicidal ideation.
B. "Life has lost its meaning for me." This statement is a strong indicator of hopelessness, which is a key risk factor for suicide. The client feels that life is meaningless, which could indicate a desire to end their life.
C. "I wish I could just take a vacation and get away from it all." While this statement may indicate stress or a desire to escape, it does not directly suggest suicidal intent.
D. "I feel like a failure and wish one thing would just go right." This statement indicates frustration and low self-worth, but it doesn't necessarily indicate an immediate risk of suicide as clearly as statement B.
Correct Answer is A
Explanation
A. "My condition is a degenerative brain disorder caused by nutrient deficiency." Wernicke encephalopathy is caused by thiamine (vitamin B1) deficiency, which is often due to chronic alcoholism. The condition is associated with neurological damage from this nutrient deficiency, making this statement accurate.
B. "There is swelling of my brain that is caused by alcohol consumption." Wernicke encephalopathy is not characterized by brain swelling but by neurological damage due to thiamine deficiency.
C. "The inability of my liver to metabolize the alcohol caused this condition." While liver dysfunction can be associated with alcohol use, Wernicke encephalopathy is specifically due to thiamine deficiency, not liver metabolism issues.
D. "Toxins from the alcohol I drank have caused my brain to swell." This statement is incorrect as Wernicke encephalopathy is related to thiamine deficiency rather than brain swelling from alcohol toxins.
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