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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The patient reports chronic severe back pain: Chronic severe back pain may indicate underlying spinal issues but does not necessarily require immediate action compared to acute symptoms such as new-onset weakness of both legs.
B. The patient expresses anxiety about having surgery: While addressing the patient's anxiety is important for providing holistic care, it is not the most immediate concern compared to new- onset weakness of both legs, which may indicate spinal cord compression requiring urgent
intervention.
C. The patient has new-onset weakness of both legs: New-onset weakness of both legs suggests potential spinal cord compression or neurological deficit requiring immediate evaluation and intervention to prevent further neurological damage or complications.
D. The patient starts to cry and says, "I feel hopeless": While addressing the patient's emotional needs is important, it is not the most immediate concern compared to addressing acute neurological symptoms such as new-onset weakness of both legs.
Correct Answer is B
Explanation
A. A rising systolic blood pressure: While increased intracranial pressure can lead to changes in blood pressure, it is not typically the first sign observed. Changes in blood pressure may occur later in the progression of increased intracranial pressure.
B. Change in mood or attention level: Changes in mood, behavior, or level of consciousness are often early signs of increased intracranial pressure. These changes may include irritability, confusion, restlessness, or lethargy.
C. Irregular respiratory rate and depth: Respiratory changes such as irregular breathing patterns or Cheyne-Stokes respirations can occur with increased intracranial pressure, but they are not typically the first sign observed.
D. A bounding radial pulse: While changes in pulse rate or quality may occur with increased
intracranial pressure, a bounding radial pulse is not typically the first sign observed. It may occur later in the progression of increased intracranial pressure as compensation mechanisms fail.
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