A nurse is caring for a client on the medical-surgical floor.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the

client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

The potential condition the client is most likely experiencing is a Hemorrhagic Stroke.

Prepare the client for a STAT CT brain: The client presents with sudden onset of severe headache described as the worst of their life, along with additional neurological symptoms such as left-sided weakness, aphasia, photophobia, and loss of peripheral vision. These symptoms are highly concerning for a possible hemorrhagic stroke, which requires urgent imaging such as a CT scan of the brain to confirm the diagnosis and guide immediate treatment.
Place the client on seizure precautions: The client has reported left-sided weakness and aphasia, indicating neurological deficits. Additionally, they have a history of atrial fibrillation and are on anticoagulant therapy with warfarin, resulting in an elevated INR of 4.9. This INR level suggests a significantly increased risk of bleeding, including intracranial bleeding. Given these factors, the client is at risk of experiencing seizures, which is a potential complication of hemorrhagic stroke. Placing the client on seizure precautions involves ensuring their safety and preventing injury in the event of a seizure.

Parameters to Monitor:

Temperature: Monitoring temperature is important to assess for the presence of fever, which could indicate an infectious process such as meningitis. However, in this case, the client's fever is likely related to their urinary tract infection rather than directly related to the stroke. Nonetheless, monitoring temperature is still essential for overall assessment and management.
PT/INR: Monitoring the PT/INR is crucial due to the client's history of atrial fibrillation and anticoagulant therapy with warfarin. The elevated INR of 4.9 suggests that the client is at increased risk of bleeding, including intracranial bleeding. Close monitoring of PT/INR levels will help guide adjustments to anticoagulant therapy and assess the risk of further bleeding complications.

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Correct Answer is A

Explanation

A. Patient has slight elevations in liver function test results: Phenytoin is primarily metabolized by the liver, and elevated liver function tests may indicate impaired liver function, potentially affecting the metabolism and clearance of phenytoin. Consultation with the healthcare provider is warranted to assess the risk-benefit ratio of administering phenytoin in the presence of liver function abnormalities.

B. Patient's most recent blood pressure is 156/92 mm Hg: While hypertension is not a contraindication for phenytoin administration, it is important to monitor blood pressure, especially considering the potential cardiovascular side effects of the medication. However, elevated blood pressure alone does not typically warrant consultation before administering phenytoin.

C. Patient experiences an aura before seizures: Experiencing an aura before seizures is a common phenomenon in patients with epilepsy and does not necessarily contraindicate the use of phenytoin. In fact, phenytoin is commonly prescribed to prevent seizures, including those preceded by an aura.

D. Patient has tonic-clonic seizures: Phenytoin is indicated for the treatment and prevention of tonic-clonic seizures, among other seizure types. Therefore, the presence of tonic-clonic seizures would not typically warrant consultation before administering phenytoin.

A. The patient reports having a stiff neck. B. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs). C. The patient reports a severe and unrelenting headache. D. The patient's blood pressure (BP) is 90/50 mm Hg

Correct Answer is D

Explanation

A. The patient reports having a stiff neck: While a stiff neck may indicate meningeal irritation, which can be associated with a subarachnoid hemorrhage, it is not as immediately concerning as hypotension, which can indicate hypovolemic shock or complications such as vasospasm.

B. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs): The presence of red blood cells in the cerebrospinal fluid is expected in a subarachnoid hemorrhage and is an important diagnostic finding but may not require immediate intervention.

C. The patient reports a severe and unrelenting headache: While a severe and unrelenting headache is a common symptom of subarachnoid hemorrhage, it is not as urgent as addressing hypotension, which can indicate hemodynamic instability and compromise perfusion to vital organs.

D. The patient's blood pressure (BP) is 90/50 mm Hg: Hypotension in a patient with a subarachnoid hemorrhage can indicate hypovolemic shock, vasospasm, or other complications. It is important to communicate this finding promptly to the healthcare provider for further
evaluation and management.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which information about a patient who has a new prescription for phenytoin (Dilantin) indicates that the nurse should consult with the health care provider before administration of the medication?

Correct Answer is A

Explanation

Which information about the patient who had a subarachnoid hemorrhage is most important to communicate to the health care provider?

Correct Answer is D

Explanation

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

Which intervention should the nurse include in the plan of care for a patient with new right- sided homonymous hemianopsia after a stroke?

A nurse is caring for a client who is scheduled to have a magnetic resonance imaging (MRI) scan. The client asks the nurse what to expect during the procedure. Which of the following statements should the nurse make?

A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?

A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased intracranial pressure (ICP). Which of the following assessment findings by the nurse supports this suspicion?

A 70-year-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first?

A nurse is caring for a client who has right-sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take?