Patient Data
The nurse considers the client's symptoms.
Which assessment finding(s) support the suspected diagnosis of acute stroke? Select all that apply.
Right leg with motor drift
Right facial paresis
Normal sensation on left hemisphere
Alert and keenly attentive
Irregular rhythm with 3+ bounding radial pulses
Right arm flaccid
Speech unintelligible
Able to follow commands
Correct Answer : A,B,F,G
Rationale:
A. Right leg with motor drift: Weakness or drift of the extremities on one side is a classic sign of hemiparesis, commonly seen in acute stroke affecting the contralateral motor cortex or corticospinal tract.
B. Right facial paresis: Facial droop or asymmetry indicates involvement of the cranial nerves or central motor pathways, consistent with a cerebrovascular event.
C. Normal sensation on left hemisphere: Normal sensation on the unaffected side is expected; it does not indicate stroke. Findings consistent with stroke would be sensory deficits on the affected side.
D. Alert and keenly attentive: Normal level of consciousness does not support acute stroke. Some strokes preserve alertness, but this finding alone is not diagnostic.
E. Irregular rhythm with 3+ bounding radial pulses: This may indicate atrial fibrillation or other cardiac arrhythmia, which is a risk factor for stroke but not a direct sign of an acute event.
F. Right arm flaccid: Flaccidity of the affected extremity is a sign of motor deficit due to stroke, reflecting loss of voluntary control on the contralateral side.
G. Speech unintelligible: Aphasia or slurred, unintelligible speech indicates involvement of language centers (usually left hemisphere), a hallmark symptom of acute stroke.
H. Able to follow commands: Following commands indicates intact comprehension and attention; while important for assessment, it does not indicate neurological deficit.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"A"}}
Explanation
Rationale for correct choices
• Decreased level of consciousness (LOC): Hemorrhagic strokes involve bleeding into the brain tissue or subarachnoid space, which increases intracranial pressure and can rapidly impair cerebral perfusion. This often results in decreased LOC or sudden deterioration in alertness. Ischemic strokes may present with normal LOC, particularly in smaller or non-dominant hemisphere infarcts.
• Unilateral symptoms: Both stroke types typically cause deficits on one side of the body corresponding to the affected cerebral hemisphere. Manifestations may include hemiparesis, facial droop, and unilateral sensory loss. The laterality of symptoms is a hallmark in both ischemic and hemorrhagic strokes.
• Sudden symptom onset: Hemorrhagic strokes usually present with abrupt, severe onset, often described as “worst headache of my life” or sudden neurological deficits. While ischemic strokes can also develop suddenly, hemorrhagic strokes generally have a more dramatic and immediate presentation.
• Alert at cognitive baseline: Many ischemic strokes, especially small-vessel infarcts, may occur without immediately affecting consciousness. Patients often remain alert and oriented at baseline, although unilateral neurological deficits are present. This contrasts with hemorrhagic strokes, where LOC is frequently compromised.
Correct Answer is ["1.3"]
Explanation
Calculation:
- Convert the infant’s weight from pounds to kilograms
Weight (kg) = 22 ÷ 2.2 = 10 kg
- Calculate the total daily dose based on weight
Total Daily Dose = 20 mg/kg × 10 kg
= 200 mg/day
- Determine the dose per administration
Doses per day = every 8 hours
24 ÷ 8 = 3 doses/day
Dose per administration = 200 ÷ 3 ≈ 66.7 mg per dose
- Calculate the volume to administer per dose
Available Concentration: 250 mg/5 mL
= 50 mg/mL
Volume to administer = Dose ÷ Concentration
= 66.7 ÷ 50
= 1.334 mL
- Rounded to the nearest tenth
= 1.3 mL
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