A patient presents to the emergency department (ED) complaining of nausea, vomiting, and the “worst headache he has ever experienced.”. While examining the patient, the nurse notes left leg and arm weakness.

The patient is immediately sent to the radiology department for a CT scan.

The registered nurse (RN) identifies the immediate need for treatment because:

A hemorrhagic brain attack is more common than an ischemic brain attack.

A thrombolytic drug will cause the peripheral and central reflexes to become hyper-reactive.

A hemorrhagic brain attack requires immediate intervention to prevent further damage.

An ischemic brain attack is less severe than a hemorrhagic brain attack.

Answer and Explanation

The Correct Answer is C

Choice A rationale
A hemorrhagic brain attack (stroke) is less common than an ischemic brain attack. Ischemic strokes account for the majority of strokes.
Choice B rationale
Thrombolytic drugs are used to treat ischemic strokes, not hemorrhagic strokes. They do not cause hyper-reactive reflexes.
Choice C rationale
A hemorrhagic brain attack requires immediate intervention to prevent further damage. Hemorrhagic strokes involve bleeding in the brain, which can rapidly worsen and cause severe damage.
Choice D rationale
An ischemic brain attack is not necessarily less severe than a hemorrhagic brain attack. Both types of strokes are serious, but hemorrhagic strokes often require more urgent intervention due to the risk of ongoing bleeding.

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Correct Answer is D

Explanation

Choice A rationale
Post-renal acute kidney injury (AKI) is caused by obstruction of urine flow, leading to decreased urine output, but it does not typically cause crackles in the lungs.
Choice B rationale
Diabetes insipidus (DI) is characterized by excessive urination and thirst due to a deficiency of antidiuretic hormone (ADH), but it does not cause crackles in the lungs.
Choice C rationale
Syndrome of inappropriate antidiuretic hormone (SIADH) involves excessive release of ADH, leading to water retention and hyponatremia, but it does not cause crackles in the lungs.
Choice D rationale
Congestive heart failure (CHF) can lead to fluid accumulation in the lungs (crackles) and decreased urine output due to poor cardiac function and renal perfusion.

A. This intracellular substance can leak into the blood with cardiac cellular injury or death. B. Elevated serum levels of troponin occur because of sustained glycogenolysis. C. This substance is elevated when a patient has acute tubular necrosis. D. Serum elevation of this acute phase reactant occurs because of tissue injury.

Correct Answer is A

Explanation

Choice A rationale
Elevated serum levels of troponin indicate cardiac cellular injury or death. Troponin is a protein released into the bloodstream when heart muscle cells are damaged, such as during a myocardial infarction.
Choice B rationale
Sustained glycogenolysis does not cause elevated troponin levels. Glycogenolysis is the breakdown of glycogen to glucose, primarily occurring in the liver and muscles, not related to troponin release.
Choice C rationale
Acute tubular necrosis does not elevate troponin levels. This condition affects the renal tubules and is typically indicated by elevated creatinine and BUN levels.
Choice D rationale
Troponin is not an acute phase reactant. Acute phase reactants are proteins whose levels change in response to inflammation, such as C-reactive protein (CRP), not troponin.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with chronic kidney disease (CKD) who has elevated intracranial pressure (ICP). While assessing the client, the nurse hears crackles in the lungs and notes a decrease in urine output.Which complication has the client likely developed?

Correct Answer is D

Explanation

What is the significance of elevated serum levels of troponin?

Correct Answer is A

Explanation

A client with a history of hypertension is admitted with a severe headache and blurred vision. Which of the following findings would indicate a hypertensive crisis?

A nurse is assessing a client with suspected meningitis. Which of the following signs would be most indicative of meningitis?

A nurse is assessing a client with a history of hypertension who presents with a severe headache, blurred vision, and confusion. The nurse should prioritize which of the following actions?

Which assessment data would indicate to the nurse that pharmacologic treatment with antibiotics and antacids has been effective for the patient diagnosed with peptic ulcer disease (PUD) secondary to H. pylori?

A client with heart failure is experiencing shortness of breath and swelling in the lower extremities. Which of the following interventions should the nurse implement first?

A nurse is caring for a client with a temperature of 38°C (100.4°F) and a heart rate of 120 beats per minute. Which condition is the client most likely experiencing?

A registered nurse (RN) is providing strategies for “better breathing” to a patient with emphysema. Successful teaching of this topic would be identified when the patient states that he will:

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with increased shortness of breath and a productive cough. The nurse notes the client’s oxygen saturation is 88% on room air. Which of the following interventions should the nurse implement first?