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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 D

Explanation

Choice A rationale

The left extrapyramidal tract is involved in motor control, but lesions here would not cause right homonymous hemianopia or inability to move the right arm. These symptoms are more indicative of a lesion in the cerebral hemisphere.

Choice B rationale

A lesion in the right cerebral hemisphere would cause left-sided symptoms, not right-sided. The patient’s symptoms are indicative of a lesion in the left cerebral hemisphere.

Choice C rationale

The cerebellum is involved in coordination and balance, not in causing right homonymous hemianopia or inability to move the right arm. These symptoms are more indicative of a lesion in the cerebral hemisphere.

Choice D rationale

A lesion in the left cerebral hemisphere can cause right homonymous hemianopia and inability to move the right arm. This is because the left hemisphere controls the right side of the body and processes visual information from the right visual field.

Correct Answer is A

Explanation

Choice A rationale

Administering supplemental oxygen is the priority intervention for a client with COPD who has an oxygen saturation of 88% on room air. This low oxygen saturation indicates hypoxemia, which requires immediate correction to prevent further respiratory distress.

Choice B rationale

Encouraging the client to use an incentive spirometer is important for lung expansion and preventing atelectasis, but it is not the priority intervention in this scenario. The immediate concern is to correct the hypoxemia.

Choice C rationale

Administering a bronchodilator as prescribed is important for managing COPD symptoms, but the priority intervention is to correct the hypoxemia by administering supplemental oxygen.

Choice D rationale

Positioning the client in high Fowler’s position can help improve breathing, but the priority intervention is to correct the hypoxemia by administering supplemental oxygen.

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