NR-325 Adult Health II - Set 3 - Part 1

Correct Answer: Reorient calmly and let the client rest

Postictal care is quiet, patient reorientation with permission to sleep while monitoring continues. Short simple sentences, repeated as often as needed, settle a client who woke frightened with no memory of events. Option a is incorrect because anything by mouth waits until the client is fully alert with an intact swallow and gag. Offering fluids to a drowsy client invites aspiration into an unprotected airway. Option b is incorrect because ambulating a confused client with sore muscles and possible transient weakness sets up a fall. Rest, not activity, is what the recovering brain and the aching body need. Option d is incorrect because repeated questioning overwhelms someone whose brain is still recovering and who has amnesia for the event. Details come from the staff who witnessed it, not from the client.

Correct Answer: The brain injury itself can trigger these outbursts

Emotional lability comes from the stroke damage rather than from how the client truly feels. Naming it for the family, redirecting attention calmly, and avoiding fuss over each episode make visits easier for everyone. Option b is incorrect because grief and sadness after a stroke are real, yet they do not switch on and off within seconds. The abrupt start and stop point to a neurologic mechanism instead. Option c is incorrect because pain produces guarding, grimacing, restlessness, and a rising pulse. Crying that appears and vanishes without any physical trigger does not fit that picture at all. Option d is incorrect because these episodes say nothing about recognition or memory. Telling a daughter that her father no longer knows her adds needless pain and misrepresents what the stroke has actually done.

Correct Answer: Ease the client down to the floor

Easing the client down prevents a fall from standing height, which is the immediate injury threat. Hazards are then moved away from the client rather than moving the convulsing client anywhere. Option a is incorrect because lifting and carrying a convulsing adult risks dropping them and injuring the nurse's back. Movement is reserved for genuine danger such as fire, water, traffic or an open stairwell. Option b is incorrect because stepping away leaves nobody watching the airway and nobody timing the event. The eyewitness account is the clinical data the provider will rely on, and it cannot be reconstructed. Option d is incorrect because forcing the legs still causes dislocation and soft tissue tearing while the seizure runs its own course anyway. Restraint is never a routine measure for a client with seizures.

Correct Answer: Thrombus forming on an atherosclerotic plaque

Stepwise worsening that starts at rest or on waking, with warning attacks in the same territory beforehand, is the signature of local clot building on plaque in a vessel already narrowed by years of disease. Option b is incorrect because cardiac emboli strike without warning and reach full severity in an instant, usually while the client is awake and active. Prior warning attacks in one territory point away from that mechanism. Option c is incorrect because rupture of a deep penetrating vessel produces bleeding, not a slowly assembling occlusion. Such a client typically has headache, vomiting, and a level of consciousness that slides downward as the hematoma expands. Option d is incorrect because an aneurysm bursting into the space around the brain announces itself with an explosive headache and neck stiffness. This client reports gradual limb weakness with no head pain at all.

Correct Answer: Global aphasia involving expression and comprehension

When a large lesion takes out both the frontal and the temporal language areas, output and understanding fail together. This is the most disabling form, and it leaves almost no reliable channel for exchanging information. Option a is incorrect because a client with the expressive form still understands. Handed a written instruction or asked a yes or no question, that client responds accurately even when speech itself is reduced to fragments. Option b is incorrect because the receptive pattern comes with plentiful speech. Words flow easily even though they carry no meaning, which is the opposite of a client limited to one repeated syllable. Option d is incorrect because slurring reflects weak articulating muscles while language stays whole. Someone with that problem grasps every instruction given and can answer in writing, which this client clearly cannot do.

Correct Answer: The hour the client went to bed

Last known well means the last moment the client was seen at baseline, which was bedtime. Sleep hides the onset, so the clock starts when someone last observed normal function, not when the deficit surfaced. Option a is incorrect because discovery time only tells you when the problem was noticed. The occlusion could have happened at any point during the night, and treating from the discovery hour would badly underestimate elapsed time. Option b is incorrect because splitting the difference is guesswork with no place in stroke documentation. Reperfusion decisions rest on an observed baseline, and inventing a midpoint could push an ineligible client toward a dangerous drug. Option c is incorrect because the call for help is simply a step in seeking care. It records how quickly the family reacted, not the neurologic baseline that every treatment window is measured from.

Correct Answer: The direct oral anticoagulant taken every day

A direct oral anticoagulant taken within the past two days blocks thrombolysis unless coagulation testing comes back normal. The team has to know this before the drug is mixed, because the bleeding risk is unacceptable. Option b is incorrect because a fracture repaired two years back sits far outside the recent trauma window. Only serious injury or surgery inside the past few weeks prompts a second look at eligibility. Option c is incorrect because a food allergy has no bearing on a thrombolytic, which contains no iodine. It would matter for contrast studies, so the team notes it without letting it delay reperfusion. Option d is incorrect because well managed asthma neither excludes treatment nor changes the dosing. Respiratory history becomes relevant if the airway is threatened, and nothing in this scenario suggests breathing trouble at present.

Correct Answer: "I will roll him onto his side and note the time."

Turning the person onto the side keeps saliva and vomit draining out of the mouth, and noting the start time tells the family when five minutes has passed and emergency services are needed. Option a is incorrect because forcing an object between clamped teeth breaks them and can be inhaled. The tongue cannot be swallowed, so there is nothing for a spoon to prevent. Option b is incorrect because pinning the limbs causes shoulder dislocation and fractures while the seizure runs its natural course. Furniture is moved away from the person rather than the person being held. Option d is incorrect because a person who has just convulsed is drowsy and cannot swallow safely yet. Drinks, food and tablets wait until full alertness returns, which may take a while.

Correct Answer: Head of bed raised with the head midline

Raising the head of the bed as ordered and keeping the head and neck neutral keeps the jugular veins open, so blood leaves the cranium freely and cerebral blood volume falls. Option b is incorrect because rotating the neck kinks the jugular veins and pressure climbs within seconds. Laying the mattress flat removes the gravity assist that helps blood drain out of the skull. Option c is incorrect because sharp hip flexion raises pressure inside the abdomen and chest, which blocks the return of blood from the head. Hips stay in mild flexion, and the knee gatch stays down. Option d is incorrect because any head-down tilt sends venous pressure straight back into the cranium. Trendelenburg is avoided in these clients even briefly, including during transfers and bedside procedures.

Correct Answer: Approach the client from the intact right side

Early in rehabilitation the nurse works within the field the client can actually see. Approaching from the intact side and keeping the call light and belongings there prevents startling and reduces the risk of injury. Option a is incorrect because standing in the blind field is exactly what produces the startle response described. The client hears a voice with no face attached to it and reacts defensively. Option b is incorrect because scanning training belongs to the later stage, once the client is stable and able to learn compensation. Asking for it on day two adds frustration without adding safety. Option c is incorrect because a call light sitting in the missing half of the visual field might as well not exist. Necessary items go where the client can find them without searching.

Correct Answer: "I will wear medical alert identification all the time."

Medical alert jewelry speaks for a client who is found postictal, confused and unable to explain the diagnosis, medications or emergency contact, which is exactly when strangers must decide what to do. Option a is incorrect because alcohol lowers the seizure threshold, interacts with these drugs and wrecks the sleep the client is trying to protect. Withdrawal after drinking carries its own seizure risk. Option c is incorrect because drowning in a tub during a seizure is a documented and preventable death. Showers replace baths, the bathroom door stays unlocked, and someone is told before the client washes alone. Option d is incorrect because driving rules for seizures are set by each state, usually as a required seizure free interval. Feeling steady is not the standard, and the clock restarts after any seizure.

Correct Answer: Intramuscular midazolam as a single dose

Benzodiazepines are the first line class in status epilepticus, and intramuscular midazolam is the route chosen when no intravenous access exists. Absorption is rapid, and respirations are watched closely afterward. Option a is incorrect because an oral route demands an alert client with an intact swallow, which this client plainly lacks. Tablets also take far too long for an emergency measured in minutes. Option b is incorrect because levetiracetam is a second line agent given after a benzodiazepine has been tried. It also needs the intravenous access this client does not currently have. Option c is incorrect because fever from sustained muscle activity is a consequence of the seizure, not its driver. Cooling measures matter, yet they never come before the drug that halts the discharge.

Correct Answer: Stop the chair and reposition the left limbs

The limbs are being injured right now, and the client will not report it because the left side is not registered at all. Stopping the chair and freeing the hand and foot removes the harm immediately. Option b is incorrect because a verbal reminder relies on awareness the client does not have. Cueing has a place in daily retraining, yet it will not pull a hand out of a spinning wheel. Option c is incorrect because charting records an event that is still in progress. Documentation follows the intervention, and writing about an injury while it continues leaves the client at risk on the way to the room. Option d is incorrect because a lap tray is a reasonable long-term adaptation ordered through occupational therapy. Requesting equipment takes hours, and the hand is caught in the spokes during this trip down the hall.

Correct Answer: Confirm the head scan shows no bleeding

Nothing that dissolves clot goes in until imaging has ruled out blood. Giving a thrombolytic to a client whose bleed was never excluded can turn a survivable stroke into a fatal one. Option a is incorrect because routine urinalysis contributes nothing to the reperfusion decision. Only the point of care glucose must return before the drug in a client with no reason to suspect a clotting problem. Option b is incorrect because catheters are avoided during the first day after thrombolysis, since each puncture creates a fresh bleeding site. Placing one now still ranks below verifying that the scan cleared the client. Option d is incorrect because giving an antiplatelet around the time of the thrombolytic raises bleeding risk. Aspirin is withheld for a full day afterward, and hanging it now would compound rather than replace the missing scan check.

Correct Answer: Diffuse axonal injury from rotational shearing

Angular forces tear axons throughout the white matter, so the client is comatose immediately while the early scan shows little. Magnetic resonance imaging is more sensitive, and management stays supportive. Option b is incorrect because a bruised frontal lobe is focal and shows on the first scan as a visible area of injury. It also tends to alter personality and judgment rather than causing instant deep coma. Option c is incorrect because arterial blood above the dura appears as a bright lens-shaped mass that no radiologist would miss. That injury also allows a lucid stretch before collapse, which never happened here. Option d is incorrect because bone driven inward is obvious on imaging and often needs surgical elevation. A normal-looking scan rules it out, and a fracture alone would not hold a client in coma.

Correct Answer: Place small bites on the unaffected right side

Food placed on the stronger side of the mouth can be felt, chewed, and moved backward under control. The weak side lets the bolus fall into the cheek or spill toward the airway. Option a is incorrect because a straw pulls thin liquid rapidly to the back of the throat before the airway closes. Straws stay off the tray for dysphagic clients unless the therapist specifically approves one. Option b is incorrect because extending the neck opens the airway entrance and shortens the distance the bolus must fall. The chin tuck does the opposite by narrowing that entrance during the swallow. Option d is incorrect because talking while eating opens the larynx at the worst possible moment. Meals for these clients run quiet, with the television off and conversation saved for afterward.

Correct Answer: Long standing high blood pressure

Hypertension tops the modifiable list for both ischemic and bleeding strokes. It damages the small penetrating vessels, speeds atherosclerosis, and drives most intracerebral hemorrhage, so controlling it prevents more strokes than any other single change. Option a is incorrect because age is the leading risk factor overall yet sits firmly in the non modifiable column. Risk roughly doubles every decade past the middle fifties, and no teaching can undo that arithmetic. Option c is incorrect because heredity raises risk through relatives who had strokes and through inherited vessel disorders. A participant cannot trade in that history, so it never answers a question about what a person can change. Option d is incorrect because sex and inherited traits are fixed at birth. Men do have higher incidence at younger ages, but pointing a class toward something unchangeable gives them nothing useful to work on at home.

Correct Answer: A bleed inside the skull nine years ago

Any history of bleeding inside the skull excludes a client from thrombolysis forever, no matter how long ago it happened. The other time based rules expire, but this one never does. Option a is incorrect because major surgery raises caution only within the preceding two weeks. Four months out, a healed joint replacement no longer represents a site that a systemic clot dissolver could reopen. Option b is incorrect because the exclusion for a previous ischemic event covers only the last three months. An episode five months back has passed that boundary and does not stand in the way of treatment. Option c is incorrect because a heart attack that far in the past carries no bleeding risk today. Only a recent infarction or pericarditis prompts individualized judgment, and eight years places this history well outside that concern.

Correct Answer: Open the airway and give oxygen

Six minutes of continuous seizure meets the definition of status epilepticus, and the first threat is hypoxia. Positioning to open the airway and delivering oxygen precede laboratory work and drug therapy. Option a is incorrect because holding a convulsing client still breaks bones and tears muscle without ending the discharge. Restraint is not used in seizure care at any point, including prolonged events. Option c is incorrect because a drug level will matter later for finding the cause, most often a missed dose. Waiting for laboratory results while the brain burns oxygen delays the treatment that stops the seizure. Option d is incorrect because transferring a convulsing adult between surfaces courts injury for the client and the staff. Emergency treatment is brought to the bedside instead of hauling the client somewhere else.

Correct Answer: Notify the provider of a possible herniation

A newly dilated, sluggish pupil signals compression of the third cranial nerve by an expanding mass on that same side. This is herniation until proven otherwise and needs immediate medical attention. Option a is incorrect because room lighting affects both pupils equally and cannot create a one-sided change. Rechecking in an hour surrenders the narrow window during which surgical decompression still helps. Option b is incorrect because harmless pupil inequality is present from birth and stays stable over time. Anything that appears between two checks is treated as structural, never dismissed as a normal variant. Option c is incorrect because eye lubrication protects a cornea when the blink reflex is gone, a comfort and safety measure unrelated to pupil size. It treats the surface while the midbrain is being crushed.