A nurse is caring for a client who presented with unilateral facial droop and weakness that lasted for about an hour before resolving spontaneausly without intervention. Which of the following is true regarding this situation?

The blockage is most likely in the right parietal region

This type of event can be one of the primary warning sign of a future stroke

The signs and symptoms are most consistent with an acute hemorrhagic stroke

The signs and symptoms are most consistent with a focal awareness seizure.

Answer and Explanation

The Correct Answer is B

A. The blockage is most likely in the right parietal region:
While a facial droop and weakness can be indicative of a stroke, the specific location of the blockage cannot be definitively determined based on the symptoms alone. A right-sided facial droop suggests that the lesion or event likely involves the left side of the brain, particularly the frontal or temporal regions, as these areas are typically associated with facial motor control. A parietal lesion would more commonly result in sensory deficits or spatial issues, not primarily facial droop. Therefore, this statement is not correct in this case.

B. This type of event can be one of the primary warning signs of a future stroke:
The client’s presentation of unilateral facial droop and weakness that resolves spontaneously within an hour is highly consistent with a transient ischemic attack (TIA). A TIA, often referred to as a "mini-stroke," is characterized by temporary neurological deficits that resolve without permanent damage. TIAs are considered warning signs of a potential future stroke, and the client should be evaluated promptly to address risk factors and prevent a more serious, permanent stroke.

C. The signs and symptoms are most consistent with an acute hemorrhagic stroke:
An acute hemorrhagic stroke typically presents with sudden and severe neurological deficits, such as a severe headache, vomiting, and loss of consciousness. Hemorrhagic strokes do not typically resolve spontaneously within an hour. The client's symptoms (unilateral facial droop and weakness that resolve within an hour) are more indicative of a TIA, not a hemorrhagic stroke. A hemorrhagic stroke would likely result in sustained deficits and a more urgent clinical presentation.

D. The signs and symptoms are most consistent with a focal awareness seizure:
Focal awareness seizures (previously known as simple partial seizures) generally involve abnormal electrical activity in a specific area of the brain, leading to symptoms such as motor twitches or sensory disturbances, but not typically a full facial droop or weakness. These seizures do not cause symptoms that resolve in such a short time, nor do they present with unilateral weakness in the manner described here. Therefore, this scenario is not consistent with a seizure disorder.

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Correct Answer is B

Explanation

A. GERD:
Gastroesophageal reflux disease (GERD) typically presents with symptoms such as heartburn, regurgitation, and chest pain. It is not related to head trauma or the symptoms described, such as severe headache, vomiting, seizure, and unresponsiveness. GERD is not associated with a fall or neurological events, making it an unlikely diagnosis in this scenario.

B. Hemorrhagic stroke:
A hemorrhagic stroke is a strong suspicion in this case, given the client’s recent fall, the report of a severe headache, vomiting, followed by a seizure and loss of consciousness. These are classic symptoms of increased intracranial pressure, which may result from bleeding in the brain, such as from a hemorrhagic stroke. The client’s hypertension (248/120 mmHg) further increases the risk of a hemorrhagic stroke, particularly in someone on long-term Warfarin, which increases the risk of bleeding. The seizure and unresponsiveness are concerning signs of significant brain injury, and a CT scan or MRI would be essential for confirming this diagnosis.
C. Septic shock:
Septic shock presents with hypotension, fever, tachycardia, and signs of infection. While the client’s elevated temperature (99.2 F) and pulse (102/min) are abnormal, they are not out of proportion to what would be expected with a head injury and potential hemorrhage. Septic shock is unlikely without signs of infection or systemic inflammatory response. The presence of a seizure, headache, and vomiting after trauma suggests a neurological emergency, not sepsis.

D. Absence seizure:
Absence seizures are brief, non-convulsive seizures characterized by a sudden interruption of consciousness, often with a blank stare and lack of motor activity. These seizures are typically seen in younger individuals and are not associated with symptoms such as a severe headache, vomiting, or unresponsiveness following head trauma. The client’s seizure, along with other concerning signs (headache, vomiting, high blood pressure), suggests a more serious neurological event like a hemorrhagic stroke rather than a simple seizure disorder.

A. Check the identifying information on the unit of blood against the patient’s ID bracelet B. Stay with the patient for 60 minutes after starting the transfusion C. Add the blood transfusion as a secondary line to the existing IV. D. Prime new primary IV tubing with lactated Ringer's Solution to use for the transfusion

Correct Answer is A

Explanation

A) Check the identifying information on the unit of blood against the patient’s ID bracelet:
This is the highest priority to ensure patient safety before beginning a transfusion. The risk of transfusion reactions, including hemolytic reactions due to mismatched blood, makes verifying patient identification critical. The nurse must match the blood product with the patient’s information and confirm that the blood product is correct for the patient. This verification is typically done with a second nurse to ensure safety. If the blood is mismatched, it can lead to severe, potentially life-threatening consequences.

B) Stay with the patient for 60 minutes after starting the transfusion:
While it is important to stay with the patient during the transfusion and monitor for adverse reactions, the highest priority before starting the transfusion is verifying patient and blood product compatibility. After starting the transfusion, staying with the patient for the first 15 minutes is critical for monitoring for early signs of a transfusion reaction, but this action occurs after the blood has been correctly matched and started.

C) Add the blood transfusion as a secondary line to the existing IV:
Ensuring proper identification and blood product matching is more critical than deciding whether to use a secondary IV line. The nurse should verify patient and blood compatibility first and then proceed with setting up the IV line for transfusion.

D) Prime new primary IV tubing with lactated Ringer's solution to use for the transfusion:
Priming IV tubing with lactated Ringer’s solution is incorrect for a blood transfusion. Blood should only be administered with normal saline, as other fluids, including lactated Ringer's solution, can cause clotting or hemolysis when mixed with blood products. This action would not be a safe or appropriate step in preparing for a blood transfusion. The correct solution to prime tubing for blood transfusions is normal saline, and this is secondary to ensuring proper patient identification and blood compatibility.

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A nurse is caring for a client who presented with unilateral facial droop and weakness that lasted for about an hour before resolving spontaneausly without intervention. Which of the following is true regarding this situation?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Before beginning a transfusion of packed red blood cells (PRBCs), which action by the nurse would be of highest priority to ensure patient safety?

Correct Answer is A

Explanation

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