A nurse is caring for a 77-year-old African American male client in the emergency department.
Based on the clients progression. Which of the following actions should the nurse take? Select all that apply:
The nurse should prepare to administer tPA.
The nurse should position the client on his right side.
The nurse should prepare to administer a bolus of 50% dextrose.
The nurse should anticipate the need for endotracheal intubation.
The nurse should prepare to administer antihypertensive medication
The nurse should use a calm and reassuring approach when interacting with the client.
The nurse should restrict all fluids and sodium intake.
Correct Answer : A,D,E,F
Choice A rationale: The nurse should prepare to administer tissue plasminogen activator (tPA). This medication is used to dissolve blood clots that have formed in the blood vessels of the brain. The client’s CT scan shows a large area of decreased attenuation in the left hemisphere, which is indicative of a stroke. The administration of tPA is time-sensitive and should be initiated as soon as possible after the onset of symptoms if there is no evidence of hemorrhage on the CT scan.
Choice B rationale: Positioning the client on his right side is not necessarily beneficial in this situation. The client is experiencing symptoms of a stroke, and positioning will not alleviate these symptoms. It is more important to focus on interventions that can potentially reverse the effects of the stroke, such as the administration of tPA.
Choice C rationale: There is no indication that the client requires a bolus of 50% dextrose. The client’s blood glucose levels are within normal limits, and hypoglycemia is not a concern at this time. Administering a bolus of 50% dextrose without indication could potentially lead to hyperglycemia.
Choice D rationale: The nurse should anticipate the need for endotracheal intubation. The client’s condition is deteriorating, and he is now unresponsive to verbal stimuli and only responds to painful stimuli. This indicates a decreased level of consciousness, which can compromise the client’s airway. Endotracheal intubation may be necessary to protect the client’s airway and ensure adequate ventilation.
Choice E rationale: The nurse should prepare to administer antihypertensive medication. The client’s blood pressure is significantly elevated, which can further exacerbate the damage caused by a stroke. Antihypertensive medication can help to lower the client’s blood pressure and reduce the risk of further complications.
Choice F rationale: The nurse should use a calm and reassuring approach when interacting with the client. This can help to reduce anxiety and promote a sense of safety. It is important to remember that the client may be scared and confused due to his symptoms, and a calm and reassuring approach can help to alleviate these feelings.
Choice G rationale: Restricting all fluids and sodium intake is not indicated in this situation. While fluid and sodium balance is important in stroke patients, there is no indication that the client is fluid overloaded or has a condition that would require sodium restriction. Furthermore, the client has been prescribed IV fluids, indicating that fluid restriction is not appropriate at this time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Bruising over the mastoid process, also known as Battle’s sign, is a classic clinical sign of a basilar skull fracture.
Choice B rationale
Pooling of blood and edema around the eyes, or ‘raccoon eyes’, is another sign of a basilar skull fracture.
Choice C rationale
The ability to recall how the injury occurred is not directly related to the presence of a basilar skull fracture. Memory loss or confusion could be symptoms of a traumatic brain injury, but they are not specific to a basilar skull fracture.
Choice D rationale
Chvostek’s sign is a clinical sign of hypocalcemia, not a basilar skull fracture
Correct Answer is C
Explanation
Choice A rationale
A contrecoup injury is indeed a “true” injury. It occurs on the side of the brain opposite to the point of impact and can have severe consequences, including brain damage. Therefore, this statement is incorrect.
Choice B rationale
The severity and healing time of contrecoup injuries can vary greatly depending on the force and location of the impact, as well as individual health factors. It’s not accurate to say that contrecoup injuries are generally less severe and heal more quickly over time.
Choice C rationale
This statement is correct. A coup injury refers to the brain damage that occurs directly under the point of impact, while a contrecoup injury occurs on the opposite side of the brain from
where the head is struck. These injuries can occur separately or together, but if the blow is strong enough, they usually appear together.
Choice D rationale
The sequence of coup and contrecoup injuries is not as this choice describes. The coup injury happens at the point of impact, and the contrecoup injury happens when the brain rebounds and hits the opposite side of the skull. Both types of injuries can impact the brain’s blood supply.
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