A nurse is caring for a client who has had a stroke.

Exhibits

Select the 3 findings that require immediate follow-up.

Drooling

Blood pressure at 1800

Breath sounds at 1000

Hoarse voice

Temperature at 1800

Answer and Explanation

Correct Answer : A,D,E

A. Drooling
Drooling can be concerning due to impaired swallowing and risk of aspiration.
D. Hoarse voice
Hoarseness after swallowing can indicate aspiration, which is a serious complication for stroke patients due to difficulty swallowing.
E. Temperature at 1800
A temperature of 39.6°C (103.3°F) is significantly elevated and suggests a potential infection, which is a serious complication after a stroke

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Correct Answer is A

Explanation

A. Lorazepam is a benzodiazepine used as the first-line treatment for status epilepticus. It rapidly terminates seizures.
B. A beta-blocker, atenolol is used for conditions like hypertension and angina, not for seizures.
C. While phenytoin is an anti-seizure medication, it has a slower onset of action compared to lorazepam. It's used as a second-line agent in status epilepticus.
D. Levetiracetam is an anti-epileptic drug, but not the first choice for acute seizure management like status epilepticus.

A. Jerking contractions of the head and neck B. Pinpoint pupils C. Pronation of the arms D. Dorsiflexion of the great toe

Correct Answer is D

Explanation

A. Jerking contractions of the head and neck is more indicative of seizures or other neurological conditions.
B. Pinpoint pupils can be associated with various conditions, including opioid overdose or pontine hemorrhage, but it's not specifically related to Babinski's sign.
C. Pronation of the arms is a general assessment finding, not specifically indicative of a neurological issue.
D. Dorsiflexion of the great toe is the classic response for Babinski's sign. It is an abnormal reflex indicating upper motor neuron damage.

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A nurse is caring for a client who has had a stroke. Exhibits Select the 3 findings that require immediate follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse cares for a client who is experiencing status epilepticus. Which medication would the nurse prepare for administration?

Correct Answer is A

Explanation

A nurse is assessing the reflexes of a client who has an unrepaired femur fracture and has suddenly become stuporous. For which of the following findings should the nurse identify that the client exhibits Babinski's sign?

Correct Answer is D

Explanation

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A nurse is caring for a client who has had a stroke. Exhibits Select the 3 findings that require immediate follow-up.

A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the findings as an indication of hypovolemic shock?

A nurse is caring for a client who has had a stroke.

Exhibits

Select the 3 findings that require immediate follow-up.