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 C

Explanation

A. The new graduate nurse elevates the client's head of the bed to 30 degrees. Elevating the head of the bed to 30 degrees helps reduce ICP by promoting venous drainage from the brain.

B. The new graduate nurse administers an analgesic before turning the client. Analgesics are often necessary before turning a client with a head injury to minimize discomfort and prevent additional stress.

C. The new graduate nurse is frequently suctioning the client without breaks: Frequent suctioning without breaks can increase intracranial pressure (ICP) and compromise the patient's condition. Suctioning should be done with caution and only as needed, allowing for breaks in between to prevent ICP elevation.

D. The new graduate nurse assesses the client's neurologic status every hour. Regular neuro assessments are necessary for patients with head injuries to monitor changes in condition.

A. 3% hypertonic saline B. Normal saline solution C. Dextrose 5% in water D. Lactated Ringers

Correct Answer is A

Explanation

A. 3% hypertonic saline: In SIADH, the body holds onto too much water, leading to dilutional hyponatremia. Hypertonic saline helps to slowly raise the sodium level and correct the dilution.

B. Normal saline solution: Normal saline (0.9%) would not be effective for SIADH as it is isotonic and would not correct the sodium imbalance.

C. Dextrose 5% in water: This would not be appropriate, as it contains free water and could exacerbate hyponatremia in a client with SIADH.

D. Lactated Ringers: This is an isotonic solution and would not effectively address the dilutional hyponatremia caused by SIADH.

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Naxlex Comprehensive Predictor Exams

The charge nurse observes a new graduate nurse who is caring for a client who has a severe head injury. Which action by the new graduate nurse requires the charge nurse to intervene?

Correct Answer is C

Explanation

The nurse is caring for a client who has developed syndrome of inappropriate antidiuretic hormone (SIADH). Which type of intravenous solution would the nurse expect to administer to the client?

Correct Answer is A

Explanation

The nurse is monitoring a 53-year-old client who is undergoing a cardiac exercise stress test after experiencing an episode of angina. Which client finding will require the test to be discontinued?

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?

The nurse is caring for a client who is postoperative following a right below-the-knee amputation. The client asks the nurse, " I keep having pain in my right foot. Why is that?" Which response would be appropriate for the nurse to make?

The nurse is assessing a client with aortic stenosis. Which finding in the client's history would the nurse identify as the most common cause of this condition?

The nurse is assessing a client with decompensated heart failure. Which finding would indicate that the client is manifesting right-sided heart failure?

After exercising, a client is hooked up to a cardiac monitor. The rhythm below is noted. How should the nurse document this rhythm?

The nurse is caring for a client on a telemetry unit. The client's cardiac monitor exhibits the rhythm below. How should the nurse document this rhythm?