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.
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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View Related questions
Correct Answer is A
Explanation
Choice A rationale
Hypersplenism is a condition often associated with cirrhosis, where the spleen becomes overactive. This leads to the destruction of blood cells, causing anemia (low red blood cells), leukopenia (low white blood cells), and thrombocytopenia (low platelets).
Choice B rationale
Peptic ulcer disease primarily affects the stomach and duodenum, leading to ulcers and bleeding. It does not typically cause anemia, leukopenia, and thrombocytopenia in the context of cirrhosis.
Choice C rationale
Cholecystitis is the inflammation of the gallbladder, usually due to gallstones. It does not cause the blood cell abnormalities seen in cirrhosis.
Choice D rationale
Esophageal varices are swollen veins in the esophagus that develop due to portal hypertension in cirrhosis. While they can cause bleeding, they do not directly cause anemia, leukopenia, and thrombocytopenia.
Correct Answer is C
Explanation
Choice A rationale
Administering diuretic medication as prescribed is an important intervention for managing fluid overload in heart failure. Diuretics help reduce fluid accumulation by increasing urine output, which can alleviate symptoms such as swelling and shortness of breath. However, before administering any medication, it is crucial to assess the client’s current respiratory status and oxygen saturation to determine the severity of their condition and ensure that the intervention is appropriate and safe.
Choice B rationale
Elevating the client’s legs can help reduce swelling in the lower extremities by promoting venous return and decreasing fluid accumulation. While this intervention can provide some relief, it does not address the immediate concern of the client’s respiratory status. Assessing the client’s respiratory status and oxygen saturation is a priority to ensure that they are receiving adequate oxygenation and to identify any potential respiratory distress that may require urgent intervention.
Choice C rationale
Assessing the client’s respiratory status and oxygen saturation is the first priority in this scenario. Heart failure can lead to pulmonary congestion and impaired gas exchange, resulting in shortness of breath and decreased oxygen levels. By assessing the client’s respiratory status and oxygen saturation, the nurse can determine the severity of the client’s condition, identify any immediate respiratory needs, and implement appropriate interventions to improve oxygenation and respiratory function.
Choice D rationale
Restricting fluid intake is a common intervention for managing fluid overload in heart failure. By limiting fluid intake, the nurse can help prevent further fluid accumulation and reduce the risk of worsening symptoms. However, this intervention does not address the immediate concern of the client’s respiratory status. Assessing the client’s respiratory status and oxygen saturation is a priority to ensure that they are receiving adequate oxygenation and to identify any potential respiratory distress that may require urgent intervention.