what are the expected findings in a patient with a thrombotic stroke

ATI RN

ATI Capstone Medical Surgical Assessment 2 Quizlet

1. What are the expected findings in a patient with a thrombotic stroke?

A. Gradual loss of function on one side of the body
B. Sudden loss of consciousness
C. Severe headache and vomiting
D. Loss of sensation in the affected limb

Correct answer: A

Rationale: The correct answer is A: Gradual loss of function on one side of the body. In a thrombotic stroke, a blood clot forms in an artery supplying blood to the brain, leading to reduced blood flow to a specific area of the brain. This results in a gradual onset of neurological deficits, such as weakness, numbness, or paralysis on one side of the body. Choices B, C, and D are incorrect because sudden loss of consciousness, severe headache and vomiting, and loss of sensation in the affected limb are more commonly associated with other types of strokes or medical conditions, not specifically thrombotic strokes. Thrombotic strokes typically present with gradual symptoms due to the gradual blockage of blood flow, leading to a progressive neurological deficit.

2. What is the priority action when the nurse administers insulin for a misread blood glucose reading?

A. Monitor for signs of hypoglycemia
B. Monitor for hyperglycemia
C. Administer glucose IV
D. Document the incident

Correct answer: A

Rationale: The priority action when the nurse administers insulin for a misread blood glucose reading is to monitor for signs of hypoglycemia. Insulin administration based on a misread blood glucose could lead to hypoglycemia due to an unnecessary dose. Monitoring for signs of hypoglycemia is crucial for prompt intervention if blood glucose levels drop dangerously low. Option B, monitoring for hyperglycemia, is incorrect in this situation as the concern is over-treatment with insulin causing hypoglycemia. Option C, administering glucose IV, is only necessary if hypoglycemia occurs. Option D, documenting the incident, is important for reporting and learning purposes but is not the immediate priority when the focus is on patient safety and preventing complications.

3. What are the early symptoms of compartment syndrome?

A. Unrelieved pain, pallor, and pulselessness
B. Localized redness and swelling
C. Fever and swelling
D. Numbness and tingling

Correct answer: A

Rationale: The correct answer is A: 'Unrelieved pain, pallor, and pulselessness.' Compartment syndrome is characterized by increased pressure within a muscle compartment, leading to reduced blood flow and potential tissue damage. Early symptoms include unrelieved pain (out of proportion to the injury), pallor (pale skin color), and pulselessness (decreased or absent pulses). Choices B, C, and D are incorrect as they do not represent the classic early symptoms of compartment syndrome.

4. A nurse in a rural community center is providing education to a group of clients about first aid interventions for snake bites. Which of the following instructions should the nurse include in the teaching?

A. Apply an ice pack directly to the affected area
B. Immobilize the affected extremity with a splint
C. Place a tourniquet above and below the affected area
D. Elevate the affected extremity

Correct answer: B

Rationale: The correct answer is to immobilize the affected extremity with a splint. This helps to slow the spread of venom by limiting movement. Applying an ice pack directly to the affected area (Choice A) is not recommended for snake bites as it could exacerbate tissue damage. Placing a tourniquet above and below the affected area (Choice C) is also not advised as it can lead to further complications. Elevating the affected extremity (Choice D) is not recommended for snake bites; keeping it below the level of the heart is more appropriate to reduce venom spread.

5. A client who has burn injuries covering their upper body is concerned about their altered appearance. Which of the following statements should the nurse make?

A. It is okay to not want to touch the burned areas of your body.
B. Cosmetic surgery should be performed within the next year to be effective.
C. Reconstructive surgery can completely restore your previous appearance.
D. It could be helpful for you to attend a support group for people who have burn injuries.

Correct answer: D

Rationale: The nurse should encourage the client to attend a support group for individuals who have burn injuries. Support groups can provide emotional support, shared experiences, and coping strategies for accepting their altered appearance. Choice A is not the best response as it does not offer proactive support. Choice B is not appropriate as the timing of cosmetic surgery should be determined by healthcare providers, not immediate. Choice C is misleading as reconstructive surgery may improve appearance but may not completely restore the previous look.