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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.

A hemorrhagic brain attack is more common than an ischemic brain attack.

B.

A thrombolytic drug will cause the peripheral and central reflexes to become hyper-reactive.

C.

A hemorrhagic brain attack requires immediate intervention to prevent further damage.

D.

An ischemic brain attack is less severe than a hemorrhagic brain attack.

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A rationale

Administering vitamin B12 to increase RBC size is not appropriate in this scenario. The elevated MCV indicates macrocytic anemia, which is often due to vitamin B12 deficiency. The goal is to restore normal RBC maturation, not to increase RBC size.

Choice B rationale

Administering vitamin B12 to restore normal RBC maturation is the appropriate action. The elevated MCV indicates macrocytic anemia, which is often due to vitamin B12 deficiency. Administering vitamin B12 will help restore normal RBC maturation and correct the anemia.

Choice C rationale

Administering medication to decrease RBC size is not appropriate in this scenario. The elevated MCV indicates macrocytic anemia, which is often due to vitamin B12 deficiency. The goal is to restore normal RBC maturation, not to decrease RBC size.

Choice D rationale

Administering iron to increase the formation of hemoglobin molecules is not appropriate in this scenario. The elevated MCV indicates macrocytic anemia, which is often due to vitamin B12 deficiency. Iron supplementation is typically used for microcytic anemia, not macrocytic anemia.

Correct Answer is A

Explanation

Choice A rationale

Serum amylase is typically elevated in acute pancreatitis. It is one of the key diagnostic markers for this condition.

Choice B rationale

Serum potassium levels are not typically elevated in acute pancreatitis. Potassium levels are more commonly associated with kidney function and electrolyte balance.

Choice C rationale

Serum calcium levels are usually decreased, not elevated, in acute pancreatitis. Hypocalcemia can occur due to fat saponification in the pancreas.

Choice D rationale

Serum sodium levels are not typically elevated in acute pancreatitis. Sodium levels are more related to overall fluid balance and kidney function.

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