The nurse is preparing to collect data for a patient's neurological status. What equipment should the nurse gather?

Blood pressure cuff

Pen light

Thermometer

Stethoscope

Answer and Explanation

The Correct Answer is B

A. A blood pressure cuff is not directly needed to assess neurological status. While blood pressure is important to monitor in neurological assessments, it is not the primary tool used for assessing neurological function.

B. A pen light is essential for assessing pupil reaction, which is a key part of a neurological exam. The nurse can use the pen light to check for pupil dilation, constriction, and reaction to light, which are important indicators of brain function.

C. A thermometer is useful for measuring body temperature but is not a primary tool for assessing neurological status. Although fever can be a sign of infection affecting the brain, it is not part of the basic neurological exam.

D. A stethoscope is useful for listening to heart and lung sounds, but it is not typically used for assessing neurological function. The pen light is the more appropriate tool for this purpose.

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Correct Answer is C

Explanation

A. A thrombotic stroke is typically caused by a blood clot that forms in an artery supplying blood to the brain, usually due to atherosclerosis. While it is a possible cause of stroke, it is not the most likely in this patient with atrial fibrillation.

B. A cerebral aneurysm involves a weakness in the blood vessel wall that can lead to rupture and bleeding, causing a hemorrhagic stroke, but this is not the most common type of stroke in patients with atrial fibrillation.

C. Embolic stroke occurs when a clot or other debris (such as a thrombus) breaks off from a distant part of the body (like the heart in atrial fibrillation) and travels to the brain, blocking a cerebral artery. This is the most common type of stroke in patients with atrial fibrillation due to the formation of clots in the left atrium that can embolize to the brain.

D. Hemorrhagic stroke is caused by the rupture of a blood vessel in the brain, leading to bleeding. It is not the most common type of stroke in patients with atrial fibrillation, though it can occur if there is coagulopathy or anticoagulant therapy.

A. ECG tracing shows irregularly irregular heart rate without P waves. B. Slurred speech C. aPTT result of 70 seconds D. Urine output is cloudy and odorous

Correct Answer is B

Explanation

A. The ECG finding of an irregularly irregular heart rate without P waves is characteristic of atrial fibrillation, which is expected in this client. This finding is not the priority in this situation.

B. Slurred speech is a potential sign of a stroke, which is a serious complication of atrial fibrillation due to the increased risk of thromboembolic events (e.g., stroke). This is the priority finding because it requires immediate intervention to assess and manage a possible stroke.

C. An aPTT of 70 seconds is slightly elevated, but it is within the therapeutic range for heparin therapy (usually 1.5 to 2.5 times the normal value). It does not warrant immediate action.

D. Cloudy and odorous urine could indicate a urinary tract infection or other issue, but it is not immediately life-threatening compared to the potential for a stroke in this client.

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The nurse is preparing to collect data for a patient's neurological status. What equipment should the nurse gather?

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