The nurse is caring for a 72-year-old patient brought to the ED with severe headache and decreasing level of consciousness. The nurse reviews the patient's assessment data to prepare the plan of care.

Exhibits

Complete the bowtie by dragging and dropping the condition the patient is most likely experiencing, two interventions the nurse would perform/anticipate related to the condition, and two parameters the nurse would monitor.

Answer and Explanation

The Correct Answer is []

Condition the Patient is Most Likely Experiencing:

Intracerebral Haemorrhage (ICH) : The patient presents with a severe headache, lethargy, decreased level of consciousness, and slurred, incomprehensible speech, which are common signs of a stroke or intracerebral haemorrhage. A history of hypertension and atrial fibrillation increases the risk for both ischemic and hemorrhagic strokes. The use of apixaban, an anticoagulant, suggests the patient is at risk for bleeding complications, including intracerebral haemorrhage.

Interventions to Perform/Anticipate:

Perform a CT Scan of the Head:
- Rationale: A CT scan will help determine if there is bleeding or an ischemic event in the brain. It is crucial for differentiating between ischemic and hemorrhagic stroke, guiding subsequent treatment.
Administer Intravenous Antihypertensives:
- Rationale: Controlling blood pressure is critical to reduce the risk of further bleeding in the brain. Immediate BP management is essential in the acute setting of suspected stroke.

Parameters to Monitor:

Neurological Status:
- Rationale: Monitoring changes in the patient’s level of consciousness, pupil reactions, and motor response will help assess the progression of the neurological deficit and effectiveness of interventions.
Blood Pressure:
- Rationale: Maintaining blood pressure within a safe range is essential to prevent exacerbation of the hemorrhage. Hypertension management is key to avoid further complications.

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Correct Answer is B

Explanation

A. "Permanent structural changes in my kidneys and eyes have already occurred.": This statement is more indicative of the complications of chronic, uncontrolled hypertension, whether primary or secondary. It does not reflect understanding that secondary hypertension is due to a specific, often treatable cause.
B. "My blood pressure can return to normal with treatment of my kidney disease.": This statement correctly reflects an understanding of secondary hypertension, which is caused by an underlying condition (like kidney disease). Treating the underlying condition can potentially normalize blood pressure.
C. "I don't know the cause of my hypertension.": This statement reflects primary (essential) hypertension, where the cause is generally unknown.
D. "My essential hypertension must be treated with medications.": This statement describes essential hypertension, not secondary. Essential hypertension typically requires lifelong medication management.

A. Assist the patient to turn to her side. B. Give an antiemetic as ordered. C. Perform a test for blood on the emesis. D. Call for an aide to get suction set up.

Correct Answer is A

Explanation

A. Assist the patient to turn to her side: This is the priority action to prevent aspiration of vomitus, which can be a serious complication for stroke patients who may have impaired swallowing and a reduced gag reflex.
B. Give an antiemetic as ordered: While important, administering an antiemetic should come after ensuring the patient’s safety and preventing aspiration.
C. Perform a test for blood on the emesis: This is not the immediate priority. Preventing aspiration is the first concern.
D. Call for an aide to get suction set up: Suction may be necessary if the patient is at risk of aspiration, but the first step is to turn the patient to prevent choking and aspiration.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The LPN/LVP is discussing types of hypertension with a patient. Which statement by the patient would reflect understanding of secondary hypertension?

Correct Answer is B

Explanation

The nurse is caring for a patient recently admitted with a stroke. The patient is experiencing nausea and begins to vomit. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A patient has been diagnosed with Raynaud's disease and asks the nurse what occurs with this disease. Which of the following is the most appropriate response?

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The nurse is reinforcing teaching provided to a patient with Raynaud disease. Which measure should the nurse include to prevent an attack?

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