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

Thrombotic stroke

Transient ischemic atack (TIA)

Embolic stroke

Hemorrhagic stroke

Answer and Explanation

The Correct Answer is D

Hemorrhagic stroke is a type of stroke that occurs when a blood vessel ruptures in the brain, causing bleeding and increased intracranial pressure. The client's symptoms of sudden, severe headache, vomiting, seizure, and

unresponsiveness are consistent with hemorrhagic stroke. The client's elevated blood pressure and temperature are also risk factors for hemorrhagic stroke.

Thrombotic stroke is a type of stroke that occurs when a blood clot forms in an artery that supplies blood to the brain, causing ischemia and tissue damage. The client's symptoms are not typical of thrombotic stroke, which usually has a gradual onset and aﬀects one side of the body.

Transient ischemic atack (TIA) is a temporary interruption of blood ﬂow to the brain, causing neurologic deficits that resolve within 24 hours. The client's symptoms are not indicative of TIA, which does not cause loss of consciousness or permanent brain damage.

Embolic stroke is a type of stroke that occurs when a blood clot or other debris travels from another part of the body to the brain, causing occlusion and ischemia. The client's symptoms are not characteristic of embolic stroke, which usually has a sudden onset and aﬀects one side of the body.

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Free Nursing Study Resources

Correct Answer is ["125"]

Explanation

To calculate the infusion rate, the nurse should use the following formula:

Infusion rate (mL/hr) = Volume (mL) / Time (hr)

Plugging in the given values, the nurse should get:

Infusion rate (mL/hr) = 250 mL / 2 hr

Infusion rate (mL/hr) = 125 mL/hr

The nurse should round the answer to the nearest whole number and use a leading zero if it applies. Therefore, the nurse should set the IV pump to deliver 125 mL/hr.

A. Hold the client's arms and legs from moving. B. Place the client back in bed. C. Place the client on his side. D. Insert a tongue blade in the client's mouth.

Correct Answer is C

Explanation

Placing the client on his side is an essential action to take during a seizure, as it can prevent airway obstruction and aspiration. The client should be placed on his side, preferably in a lateral recumbent position, to allow saliva and secretions to drain from the mouth.

Holding the client's arms and legs from moving is not appropriate, as it can cause injury, increase agitation, or prolong the seizure. The client should be allowed to move freely during a seizure, but supported and guided away from hazards.

Placing the client back in bed is not necessary, as it can cause harm or delay care. The client should be left on the ﬂoor, unless it is unsafe or uncomfortable, and padded with pillows or blankets to protect from injury.

Inserting a tongue blade in the client's mouth is not advisable, as it can cause oral trauma, choking, or damage to the teeth. The client should not have anything inserted into his mouth during a seizure, as he cannot swallow or bite his tongue. The nurse should ensure that the client's airway is clear and patent.

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["125"]

Explanation

A nurse enters a client's room and finds the client on the ﬂoor having a seizure. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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