A nurse in the emergency department is caring for a client who had a seizure and became unresponsive after stating they had a sudden, severe headache. 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 neurological disorders should the nurse suspect?

Embolic stroke

Thrombotic stroke

Transient ischemic attack (TIA)

Hemorrhagic stroke

Answer and Explanation

The Correct Answer is D

Choice A. An embolic stroke is caused by an embolus, often a blood clot, that travels to the brain from another part of the body. It does not typically present with a sudden, severe headache.

Choice B. A thrombotic stroke occurs when a blood clot forms inside one of the brain's arteries. While it can cause a headache, it is not usually characterized by a sudden, severe headache.

Choice C. A transient ischemic attack (TIA) is often called a mini-stroke and symptoms are temporary. A sudden, severe headache is more indicative of a hemorrhagic stroke.

Choice D. A hemorrhagic stroke, which involves bleeding within the brain, is most likely to cause a sudden, severe headache, and can lead to seizures and changes in consciousness.

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Correct Answer is A

Explanation

Choice A reason:Placing the client in a sitting position helps to lower blood pressure by promoting venous return and is the first action to take in cases of autonomic dysreflexia²³.

Choice B reason:While examining for skin breakdown is important, it is not the first action to take when autonomic dysreflexia is suspected.

Choice C reason:Checking the bladder for distention is a critical step, but it should be done after positioning the client to address immediate blood pressure concerns.

Choice D reason:Checking for fecal impaction is also important but follows the initial step of positioning the client to manage blood pressure.

A. Administer antiemetics as needed. B. Administer analgesics as needed. C. NPO (nothing by mouth) until pain-free. D. Monitor blood glucose and provide insulin as needed. E. Side-lying or fetal position. F. Monitor hydration status.

Correct Answer is ["A","B","C","D","F"]

Explanation

Choice A: Administer antiemetics as needed Reason: Acute pancreatitis often causes severe nausea and vomiting. Antiemetics are administered to control these symptoms and prevent further complications such as dehydration and electrolyte imbalance.

Choice B: Administer analgesics as needed Reason: Pain management is a crucial part of the treatment for acute pancreatitis. The condition can cause severe abdominal pain, and analgesics are administered to provide relief.

Choice C: NPO (nothing by mouth) until pain-free Reason: The goal in treating acute pancreatitis is to allow the pancreas to rest and recover from the inflammation3. Keeping the patient NPO (nothing by mouth) helps achieve this by reducing the stimulation and workload of the pancreas.

Choice D: Monitor blood glucose and provide insulin as needed Reason: Acute pancreatitis can affect the pancreas’ ability to produce insulin, leading to elevated blood glucose levels. Therefore, monitoring blood glucose levels and administering insulin as needed is an important part of the management plan.

Choice E: Side-lying or fetal position Reason: While the side-lying or fetal position might help some patients with abdominal pain, it is not a standard intervention for acute pancreatitis. Therefore, this option is not correct.

Choice F: Monitor hydration status Reason: Patients with acute pancreatitis are at risk of dehydration due to symptoms like vomiting and decreased oral intake. Monitoring hydration status is crucial to ensure appropriate fluid replacement.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dysreflexia. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A client is admitted to the medical unit with acute pancreatitis. While planning care for this client, the nurse will include which of the following interventions? (Select all that apply).

Correct Answer is ["A","B","C","D","F"]

Explanation

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