A nurse in an emergency department is caring for a client who became unresponsive after stating she had a sudden, severe headache with vomiting and then seizure activity. The client's vital signs are as follows: blood pressure of 198/110 mm Hg pulse of 82 bpm, respirations of 24/min, and a temperature of 100.8 F (38.2° C). Which neurologic disorder would the nurse suspect?

Thrombotic stroke

Embolic stroke

Hemorrhagic stroke

Transient ischemic attack (TIA)

Answer and Explanation

The Correct Answer is C

A. Thrombotic stroke. A thrombotic stroke develops more gradually and is not typically associated with such sudden and severe symptoms.

B. Embolic stroke. An embolic stroke is often associated with a known embolic source, such as a clot from the heart, and can present more suddenly, but without all the symptoms seen here.

C. Hemorrhagic stroke: Hemorrhagic strokes often present with a sudden, severe headache, vomiting, seizure activity, and high blood pressure. A fever may also develop due to increased intracranial pressure.

D. Transient ischemic attack (TIA). TIAs are brief and resolve within minutes to hours and do not typically cause seizures.

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Correct Answer is B

Explanation

A. Decerebrate posturing: This involves extension and outward rotation of the arms, which is not observed here.

B. Decorticate posturing: Internal rotation, adduction, and flexion of the arms are characteristic of decorticate posturing, indicating damage to the corticospinal tract.

C. Flexion withdrawal: This refers to pulling away from a painful stimulus and does not involve the described pattern of movement.

D. Localization of pain: This is an intentional movement toward the source of pain, which is not demonstrated in this scenario.

A. Start CPR B. Prepare for radiofrequency catheter ablation C. Prepare for defibrillation D. Prepare for cardioversion

Correct Answer is D

Explanation

A. Start CPR: CPR is indicated if the client is unresponsive and pulseless, which is not the case here as the client is alert.

B. Prepare for radiofrequency catheter ablation: This is a long-term treatment for recurrent VT but not appropriate for acute management.

C. Prepare for defibrillation: Defibrillation is used for pulseless VT or ventricular fibrillation, not for a stable VT with a pulse.

D. Prepare for cardioversion: Synchronized cardioversion is the appropriate intervention for a stable VT with a pulse to restore normal rhythm.

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Naxlex Comprehensive Predictor Exams

The nurse is assessing a brain-injured client response to nail bed pressure. The client demonstrates internal rotation, adduction, and flexion of the arms, the nurse should report the response as which finding

Correct Answer is B

Explanation

A nurse is caring for an alert client who reports heart palpitations, nausea, and dizziness. An electrocardiogram (EKG) confirms the client is experiencing vector tachycardia (VT). The nurse should anticipate which action?

Correct Answer is D

Explanation

A 55-year-old client who is diagnosed with an evolving myocardial infarction (MI) insists on going home. The nurse encourages the client to be admitted because he knows that within the first 24 hours of a MI, there is a high risk for which of the following?

The health care provider prescribes IV mannitol for a client with an intracranial pressure (ICP) of 22. How will the nurse determine that the medication had the intended effect?

The nurse is caring for a client who is terminally and approaching the end of life. Which goal would the nurse identify as the priority?

A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor the client for which finding?

A nurse is admitting a client who has acute heart failure following myocardial infarction (MI) Which order by the provider requires clarification by the nurse?

The nurse is assessing the cardiac rhythm of a client who is admitted with coronary artery disease. The nurse notes that the PR interval is 0.24 and the QRS interval is 0.10. Which interpretation would be appropriate for the nurse to make

The nurse is assessing a client with unstable angina. Which finding would the nurse expect the client to report that differentiates this from other types of anginas?