A patient arrives in the emergency department exhibiting symptoms of a cerebrovascular accident (CVA). Which diagnostic evaluations would the nurse anticipate before treatment is initiated?
Prothrombin level
Brain CT or MRI
Chest x-ray
Lumbar puncture
The Correct Answer is B
Choice A rationale
While prothrombin level is an important test in evaluating blood clotting disorders, it is not typically used in the initial diagnostic evaluations for a cerebrovascular accident (CVA) or stroke.
Choice B rationale
Brain CT or MRI scans are commonly used in the initial diagnostic evaluations for a CVA. These imaging tests can show bleeding in the brain, an ischemic stroke, a tumor, or other conditions.
Choice C rationale
A chest x-ray is not typically used in the initial diagnostic evaluations for a CVA. It is more commonly used to diagnose conditions affecting the lungs and heart.
Choice D rationale
A lumbar puncture, or spinal tap, may be used in some cases to help diagnose a CVA, but it is not typically part of the initial diagnostic evaluations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Status epilepticus is a medical emergency characterized by continuous or rapid-fire seizures. Intravenous diazepam is one of the first-line treatments for this condition. It works by enhancing the effect of gamma-aminobutyric acid (GABA), a neurotransmitter that inhibits brain activity, thereby helping to stop the seizure.
Choice B rationale
Oral lorazepam is not typically used to halt a seizure immediately due to its slower onset of action compared to intravenous administration.
Choice C rationale
Oral phenytoin is not typically used to halt a seizure immediately. It is more commonly used for the long-term management of seizures.
Choice D rationale
Intravenous phenobarbital is a second-line treatment for status epilepticus, used when first- line treatments such as diazepam are ineffective.
Correct Answer is A
Explanation
Choice A rationale
The best way to determine if a patient can safely and effectively self-administer medications is to ask the patient to demonstrate the instillation of the medications. This allows the nurse to directly observe the patient’s technique, identify any errors, and provide immediate feedback and instruction. It also gives the patient an opportunity to ask questions and clarify any misunderstandings. This method is often referred to as the “show-back” or “teach-back” method and is widely used in patient education to confirm understanding and competency.
Choice B rationale
While assessing the patient for any previous inability to self-manage medications can provide useful information, it does not directly assess the patient’s ability to self-administer the new eye medications. Previous difficulties may be due to factors that do not apply to the current situation, such as complex medication regimens, cognitive impairment, or lack of resources.
Choice C rationale
Although the patient accurately describing the directions for administering the medications indicates that the patient understands the instructions, it does not necessarily mean that the patient can perform the task correctly. Physical limitations, dexterity issues, or misunderstanding of the instructions can still result in incorrect administration.
Choice D rationale
Assessing the patient’s functional status can provide valuable information about the patient’s overall ability to perform activities of daily living, including medication management.
However, it does not specifically assess the patient’s ability to self-administer eye medications.
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