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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Correct Answer is A
Explanation
Choice A rationale
Autonomic neuropathy is a common complication of diabetes and can affect various autonomic functions, including heart rate, blood pressure, and digestion. It is caused by damage to the autonomic nerves due to prolonged high blood sugar levels.
Choice B rationale
Diabetic-induced leukocyte depletion is not a recognized complication of diabetes. Diabetes primarily affects blood vessels and nerves rather than causing leukocyte depletion.
Choice C rationale
Diabetic-induced angiopathy refers to damage to blood vessels caused by diabetes. While it is a recognized complication, autonomic neuropathy is more directly related to diabetic-induced complications.
Choice D rationale
Overdrive of the RAAS (renin-angiotensin-aldosterone system) is not a specific complication of diabetes. While diabetes can affect the RAAS, it is not the most likely condition related to diabetic-induced complications.
Correct Answer is A
Explanation
Choice A rationale
A positive Brudzinski’s sign is indicative of meningitis. It involves involuntary lifting of the legs when the neck is flexed, suggesting meningeal irritation.
Choice B rationale
A positive Babinski’s sign indicates central nervous system pathology but is not specific to meningitis. It involves dorsiflexion of the big toe when the sole of the foot is stimulated.
Choice C rationale
A positive Romberg’s sign indicates issues with proprioception and balance but is not specific to meningitis. It involves swaying or falling when standing with eyes closed.
Choice D rationale
A positive Murphy’s sign indicates gallbladder inflammation (cholecystitis) and is not related to meningitis. It involves pain on palpation of the right upper quadrant during inspiration.