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 ["A","B","C","E"]

Explanation

A. Compartment syndrome: This is a serious complication that can occur with fractures, including femur fractures. It occurs when increased pressure in the muscle compartment impairs circulation and nerve function.

B. Hemorrhage: Fractures, particularly of long bones like the femur, can result in significant bleeding. Monitoring for hemorrhage is important.

C. Deep vein thrombosis (DVT): DVT is a common complication in clients with fractures and immobilization. The client is at risk for blood clots forming in the legs due to limited movement and prolonged bed rest.

D. Complex regional pain syndrome: While this can occur after fractures, it is less common and typically develops weeks to months after the injury.

E. Fat embolism: A fat embolism is a potential complication of long bone fractures, especially the femur. Fat globules can enter the bloodstream and cause respiratory distress, neurological impairment, and petechial rash.

A. Document the finding and continue to monitor the client. B. Prepare the client for temporary pacemaker insertion. C. Notify the client's health care provider immediately and then administer epinephrine IV. D. Administer atropine per agency bradycardia protocol and then notify the health care provider

Correct Answer is A

Explanation

A. Document the finding and continue to monitor the client: A PR interval of 0.24 seconds indicates first-degree AV block, which is often asymptomatic and benign if vital signs are stable. No immediate intervention is required other than continued monitoring.

B. Prepare the client for temporary pacemaker insertion: Pacemakers are not indicated for asymptomatic first-degree AV block.

C. Notify the health care provider immediately and then administer epinephrine IV: This is unnecessary as the client is stable and shows no signs of hemodynamic compromise.

D. Administer atropine per agency bradycardia protocol and then notify the health care provider: Atropine is not required for a stable heart rate of 72 bpm.

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Naxlex Comprehensive Predictor Exams

A client is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The client has been placed in traction until his femur can be surgically repaired. What complications should the nurse monitor for? Select All That Apply

Correct Answer is ["A","B","C","E"]

Explanation

The nurse is evaluating a cardiac monitor strip for their client that displays a sinus rhythm with a heart rate of 72 bpm. The PR interval is 0.24 seconds. The vital signs are stable and the client reports no symptoms. What is the most appropriate nursing intervention?

Correct Answer is A

Explanation

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