A patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving a prescribed dose of aspirin?
The patient has dysphasia.
The patient has atrial fibrillation.
The patient has a history of brief episodes of right-sided hemiplegia.
The patient reports that symptoms began with a severe headache.
The Correct Answer is D
A. The patient has dysphasia: Dysphasia (difficulty with speech) is a common symptom of stroke but does not contraindicate the use of aspirin for acute ischemic stroke management. Aspirin is routinely administered in the acute phase of ischemic stroke to prevent further clot formation.
B. The patient has atrial fibrillation: Atrial fibrillation increases the risk of embolic strokes, and aspirin may be used for stroke prevention in certain cases. However, the presence of atrial fibrillation alone does not indicate a contraindication to aspirin administration in the acute setting of a suspected stroke.
C. The patient has a history of brief episodes of right-sided hemiplegia: A history of transient ischemic attacks (TIAs) or brief episodes of hemiplegia suggests a risk factor for stroke but does not necessarily contraindicate the use of aspirin in the acute phase of stroke
management. Aspirin is commonly used for secondary prevention after TIAs or minor strokes.
D. The patient reports that symptoms began with a severe headache: Severe headache as the initial symptom of stroke raises concerns about a possible hemorrhagic stroke rather than an ischemic stroke. Administration of aspirin in the setting of a hemorrhagic stroke can worsen bleeding and increase morbidity and mortality. Therefore, the nurse should consult with the healthcare provider before giving aspirin to determine the appropriate course of action based on the patient's presentation and diagnostic evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","E","F"]
Explanation
A. Suction Tubing: This equipment is necessary for clearing the patient's airway in case of any secretions or vomitus that could obstruct breathing following a seizure episode.
B. Nasogastric Tube: While nasogastric tubes may be necessary in some medical conditions, they are not typically indicated following treatment for status epilepticus unless there are specific concerns related to the patient's condition that require gastric decompression or feeding.
C. Urinary Catheter: While urinary catheters may be used in some cases, they are not routinely required following treatment for status epilepticus unless there are specific concerns about urinary retention or monitoring of urine output.
D. Tongue Blade: Tongue blades are not typically necessary following treatment for status epilepticus. They may pose a risk of injury to the patient if used unnecessarily.
E. Oxygen Mask: Oxygen masks are essential for providing supplemental oxygen to the patient, especially if there are concerns about hypoxia following a seizure episode.
F. Side Rail Pad: Side rail pads are important for preventing injury to the patient during postictal confusion or agitation. They help to protect the patient from accidentally falling out of bed or injuring themselves against the bed rails.
Correct Answer is B
Explanation
A. Monitor level of consciousness (LOC): While monitoring the patient's level of consciousness is important, administering medication to stop the seizure takes precedence to prevent potential complications associated with prolonged seizure activity.
B. Administer lorazepam (Ativan) 4 mg IV: The priority in managing continuous tonic-clonic seizures is to terminate the seizure activity promptly. Lorazepam is a benzodiazepine that can help to abort seizures and is often used as first-line treatment in the acute setting.
C. Obtain computed tomography (CT) scan: While obtaining diagnostic imaging such as a CT scan may be necessary to evaluate for underlying causes of the seizure, it is not the first
intervention in the acute management of continuous seizures. Stabilizing the patient and stopping the seizure activity take precedence.
D. Give phenytoin (Dilantin) 100 mg IV: Phenytoin is an antiepileptic medication that is used for long-term management of seizures but is not typically administered as first-line treatment during an acute seizure episode. Benzodiazepines like lorazepam are preferred for immediate seizure control.
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