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?
Embolic stroke.
Hemorrhagic stroke.
Transient ischemic attack (TIA).
Thrombotic stroke.
The Correct Answer is B
This scenario requires the application of neurovascular pathophysiology and clinical assessment skills. Understanding the distinct presentation of intracranial bleeding versus ischemic events is essential, specifically focusing on the relationship between sudden onset severe headache, projectile vomiting, and extreme hypertension in neurological emergencies.
Choice A rationale
Embolic strokes usually present with sudden focal deficits but rarely cause a thunderclap headache or significant vomiting unless brainstem involvement occurs. They result from a dislodged clot traveling to cerebral arteries, often during physical activity or exertion.
Choice B rationale
Hemorrhagic stroke involves the rupture of a blood vessel, leading to increased intracranial pressure. This pressure triggers the classic triad of sudden severe headache, vomiting, and altered consciousness, often accompanied by dangerously high blood pressure readings.
Choice C rationale
Transient ischemic attacks represent temporary blockages of blood flow that resolve within twenty-four hours without permanent damage. These episodes do not typically cause severe hypertension, vomiting, or prolonged unresponsiveness characteristic of a major intracranial event.
Choice D rationale
Thrombotic strokes are caused by gradual narrowing of an artery due to plaque, often manifesting during sleep or rest. The onset is typically slower than a hemorrhage and lacks the sudden, explosive headache and vomiting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Nursing prioritization relies on the ABC framework and identifying the most immediate threat to life. Knowledge of electrolyte imbalances and cardiac conduction must be applied here to recognize that severe hyperkalemia poses an imminent risk of lethal cardiac arrhythmias.
Choice A rationale
A low grade fever of 38.2 C on the first postoperative day is common due to the inflammatory response or atelectasis. While it requires monitoring and lung expansion exercises, it is not an immediate life threat.
Choice B rationale
Severe abdominal pain and nausea are classic symptoms of acute pancreatitis. While the patient is in significant distress and needs analgesia, this presentation is expected for the diagnosis and is second to cardiovascular instability.
Choice C rationale
Confusion and asterixis in cirrhosis indicate hepatic encephalopathy due to elevated ammonia. Normal ammonia is 15 to 45 mcg/dL. This requires treatment with lactulose but is less immediately fatal than a cardiac arrest.
Choice D rationale
A potassium level of 6.8 mEq/L is critically high, as the normal range is 3.5 to 5.0 mEq/L. Peaked T waves indicate myocardial irritability, which can progress rapidly to ventricular fibrillation or asystole, requiring emergent intervention..
Correct Answer is C
Explanation
The clinical presentation of asterixis and lethargy in liver failure indicates hepatic encephalopathy. Knowledge of nitrogenous waste metabolism and the pharmacological action of osmotic laxatives is necessary to address the buildup of neurotoxic ammonia levels within the systemic circulation.
Choice A rationale
Vitamin K is essential for synthesizing clotting factors II, VII, IX, and X in the liver. While liver failure causes coagulopathy, this intervention does not address the neurological symptoms caused by elevated ammonia or metabolic encephalopathy.
Choice B rationale
Historically, protein restriction was used to limit ammonia production. However, modern guidelines emphasize maintaining adequate protein intake to prevent muscle wasting and malnutrition, which can actually worsen the clinical outcomes and metabolic status in cirrhotic patients.
Choice C rationale
Lactulose is a synthetic disaccharide that acidifies colonic contents. This converts ammonia into ammonium, which is poorly absorbed and excreted via stool. It is the gold standard for reducing neurotoxic ammonia levels in hepatic encephalopathy.
Choice D rationale
Sodium restriction is primarily utilized to manage fluid retention and ascites in portal hypertension. While important for volume control, it does not directly impact the cerebral edema or neurotoxicity associated with the presence of asterixis.
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