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RN Medsurg Exam 15

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1 : A nurse is caring for a 77-year-old African American male client in the emergency department.

The client presented to the emergency department via EMS with reports of arm problems and a headache. The sudden headache was followed by loss of vision in the right eye for several seconds, right arm numbness, and weakness that started "20 minutes ago."

The client's condition seems to be deteriorating. He is now experiencing difficulty speaking and appears to be confused. His right arm weakness has progressed, and he is unable to lift it. He also reports a persistent headache that he rates as 7 on a scale of 0 to 10.

(1200hrs): The client's condition continues to worsen. He is now unresponsive to verbal stimuli and only responds to painful stimuli. His right arm and leg remain immobile. The headache persists, and he is now unable to communicate verbally. His family is present and very concerned about his condition.

(1100hrs)

The client's right pupil is dilated and non-reactive to light. His speech is slurred, and he is unable to follow simple commands. His right arm shows no movement, and his right leg shows decreased movement. He is unable to smile symmetrically.

(1200hrs)

The client's right pupil remains dilated and non-reactive to light. He shows no response to verbal commands and only withdraws from painful stimuli. His right side remains immobile, and his facial droop has worsened.

(1100hrs)

CT scan: Shows a large area of decreased attenuation in the left hemisphere.

Blood glucose: 120 mg/dL

ECG: Shows atrial fibrillation

(1200hrs)

Repeat CT scan: Confirms large area of decreased attenuation in the left hemisphere with no evidence of hemorrhage.

Blood glucose: 118 mg/dL

ECG: Persistent atrial fibrillation

(1100hrs)

• Administer tissue plasminogen activator (tPA) if CT results are negative for hemorrhage.

• Start IV fluids.

• Monitor neurological status every 15 minutes.

(1200hrs)

• Continue monitoring neurological status every 15 minutes.

• Prepare for possible intubation if respiratory status declines.

• Administer antihypertensive medication to manage blood pressure.

Based on the client’s progression. Which of the following actions should the nurse take? Select all that apply:

Answer Options

The nurse should prepare to administer tPA.

The nurse should position the client on his right side.

The nurse should prepare to administer a bolus of 50% dextrose.

The nurse should anticipate the need for endotracheal intubation.

The nurse should prepare to administer antihypertensive medication

The nurse should use a calm and reassuring approach when interacting with the client.

The nurse should restrict all fluids and sodium intake.

Hint : Time-sensitive stroke treatment.

Correct Answers:

The nurse should prepare to administer tPA.
The nurse should anticipate the need for endotracheal intubation.
The nurse should prepare to administer antihypertensive medication
The nurse should use a calm and reassuring approach when interacting with the client.

Rationale :

Prepare to administer tPA CT confirms ischemic stroke (no hemorrhage), and tPA is standard treatment for ischemic stroke within the time window. Anticipate the need for endotracheal intubation: The client is unresponsive with worsening neurological status, risking airway compromise. Prepare to administer antihypertensive medication: The provider ordered BP management to prevent further stroke damage while maintaining perfusion. Use a calm and reassuring approach: The client is unresponsive, but the family is distressed; a calming presence reduces anxiety.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

QLexNursing

1 : A nurse is caring for a 77-year-old African American male client in the emergency department.

Answer Options

2 : A nurse is caring for a client admitted with meningitis. The student nurse asks, "I know that the client has a lot of edema in the brain, but what causes it?" Which of the following responses from the nurse best answers the student's query?

3 : A nurse is caring for a client who has phantom limb pain. The nurse should identify the client is experiencing which type of pain?

4 : A nurse is caring for a client who has chronic migraine headaches. The client asks if they had a cerebral aneurysm; which of the following responses should the nurse use?

5 : A nurse is caring for a client who has a traumatic brain injury (TBI). Which of the following secondary conditions should the nurse anticipate the client might develop?

6 : A nurse is reinforcing teaching to a group of nursing students about possible psychosocial changes a client might have after sustaining a neurological injury. Which of the following should the nurse mention?

7 : A nurse is caring for a client who has a subarachnoid hemorrhage and asks why they are having a CT angiography. Which of the following should the nurse understand about CT angiography?

8 : A nurse is evaluating a patient for signs of pain. Which of the following is an objective sign of pain?

9 : A nurse is gathering neurological data on a patient with a neurological injury and observes signs indicative of Cushing's Triad. The nurse understands that Cushing's Triad is a nervous system response that could prevent which of the following conditions?

10 : A nurse is admitting a patient with a subarachnoid hemorrhage and expects to administer which of the following medications to decrease intracranial pressure (ICP)?