A nurse is caring for a client who has a seizure disorder. The client asks the nurse how seizures occur. Which of the following responses by the nurse is appropriate?

"Seizures occur when there is too much stimulation in your brain cells."

"Seizures occur when there is an imbalance in your brain chemicals."

"Seizures occur when there is a lack of oxygen in your brain tissue."

"Seizures occur when there is an infection in your brain tissue."

Answer and Explanation

The Correct Answer is B

Choice A reason:

This is an incorrect answer, as seizures do not occur due to too much stimulation in brain cells, but rather due to abnormal electrical activity caused by neurotransmitter imbalance.

Choice B reason:

This is a correct answer, as seizures occur due to neurotransmitter imbalance, which disrupts communication between neurons and causes abnormal electrical activity in the brain.

Choice C reason:

This is an incorrect answer, as seizures do not occur due to lack of oxygen in brain tissue, but rather due to abnormal electrical activity caused by neurotransmitter imbalance.

Choice D reason:

This is an incorrect answer, as seizures do not occur due to infection in brain tissue, but rather due to abnormal electrical activity caused by neurotransmitter imbalance.

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Correct Answer is ["A","B","C","E"]

Explanation

Choice A reason:
This is correct because monitoring the client's vital signs and neurological status frequently can help detect any changes in the client's condition, such as improvement or deterioration of symptoms, or complications such as bleeding or increased intracranial pressure.

Choice B reason:
This is correct because administering rtPA within 4.5 hours of symptom onset can increase the chances of restoring blood flow to the ischemic brain tissue and reducing neurological damage. The effectiveness and safety of rtPA decrease after this time window.

Choice C reason:
This is correct because maintaining the client's systolic blood pressure below 180 mm Hg can prevent further ischemia or hemorrhage in the brain. High blood pressure can increase the risk of bleeding or reperfusion injury after thrombolytic therapy.

Choice D reason:
This is incorrect because giving aspirin or other antiplatelet agents along with rtPA can increase the risk of bleeding or hemorrhagic transformation. Antiplatelet agents should be avoided for at least 24 hours after thrombolytic therapy.

Choice E reason:
This is correct because assessing the client for signs of bleeding or hemorrhagic transformation can help identify any adverse effects of thrombolytic therapy. Bleeding or hemorrhagic transformation can manifest as hematuria, hematemesis, melena, petechiae, ecchymosis, epistaxis, gingival bleeding, headache, altered mental status, or worsening neurological deficits.

A. "I can move my arm and leg on the affected side better than before." B. "I can speak more clearly and understand what others are saying." C. "I can swallow without choking or coughing." D. All of the above.

Correct Answer is D

Explanation

Choice A reason:

This is correct because improved movement of the arm and leg on the affected side indicates an improvement in motor function, which can be impaired by ischemic stroke.

Choice B reason:

This is correct because improved speech and comprehension indicate an improvement in language function, which can be impaired by ischemic stroke, especially if it affects the dominant hemisphere.

Choice C reason:

This is correct because improved swallowing indicates an improvement in cranial nerve function, which can be impaired by ischemic stroke, especially if it affects the brainstem.

Choice D reason:

This is correct because all of the above statements indicate an improvement in functional recovery, which is the goal of rehabilitation for clients who have ischemic stroke.

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A nurse is caring for a client who has a seizure disorder. The client asks the nurse how seizures occur. Which of the following responses by the nurse is appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has ischemic stroke and is receiving thrombolytic therapy with recombinant tissue plasminogen activator (rtPA). Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","B","C","E"]

Explanation

A nurse is evaluating the outcomes of a client who has ischemic stroke and has received rehabilitation. Which of the following statements by the client indicates an improvement in functional recovery?

Correct Answer is D

Explanation

A nurse is educating a client who has a history of ischemic stroke about modifiable risk factors. Which of the following risk factors should the nurse include in the teaching? (Select all that apply.)

A nurse is reviewing the medical history of a client who has ischemic stroke. Which of the following conditions is the most common cause of ischemic stroke?

A nurse is assessing a client who has peripheral neuropathy due to diabetes mellitus. Which of the following findings should the nurse expect?

A nurse is caring for a client who has a seizure disorder. The client asks the nurse how seizures occur. Which of the following responses by the nurse is appropriate?

A nurse is teaching a client about the functions of the central nervous system (CNS). Which of the following statements by the client indicates a need for further teaching?

A nurse is caring for a client who has multiple sclerosis (MS). Which of the following statements by the client indicates an understanding of this condition?

A nurse is planning care for a client who has ischemic stroke and is at risk for cerebral edema. Which of the following interventions should the nurse include in the plan?