A 70-year-old female presents to the emergency department through triage with a noticeable facial droop and garbled speech. After having a few drinks at a local seafood restaurant, the client's husband noticed his wife's speech became difficult to understand.

Flow sheets

1915

Arrival at emergency department

1920

Vital Signs:

- Temperature: 98.2° F (36.8° C)

- Heart rate: 92 beats/minute

- Respirations: 24 breaths/minute

- Blood pressure: 210/98 mmHg

- Oxygen saturation: 95% on room air

Imaging studies

1935

Head CT scan results:

- No evidence of intracranial hemorrhage

- No evidence of acute disease

Orders

- Obtain CT scan of the head.

- Insert a large bore peripheral IV.

- Start normal saline infusion at 50 mL/hour.

The nurse administered tPA and conducted neurologic assessments every 15 minutes during the infusion.

The tPA infusion finished and the nurse performed neurologic assessments every 30 minutes for the 6 hours following the administration.

The client was noted to be stable with unchanged neurologic assessments.

The nurse begins to plan care for the client's recovery and identifies interdisciplinary team members who can assist with the client's recovery.

Select the interdisciplinary team members who should assist the client in recovery.

Occupational Therapist

Speech Therapist

Case manager

Physical therapist

Chief Nursing Officer

Answer and Explanation

Correct Answer : A,B,C,D

- Choice A: Occupational therapist. This is correct because an occupational therapist can help the client with activities of daily living (ADLs) such as dressing, grooming, eating, and toileting. The client may have difficulty performing these tasks due to the facial droop and weakness caused by the stroke.

- Choice B: Speech therapist. This is correct because a speech therapist can help the client with communication and swallowing problems. The client has garbled speech, which indicates a possible aphasia or dysarthria. The client may also have dysphagia, which is difficulty swallowing, due to the impaired coordination of the muscles involved in swallowing.

- Choice C: Case manager. This is correct because a case manager can coordinate the client's care and discharge planning. The case manager can arrange for referrals, home health services, equipment, and follow-up appointments as needed. The case manager can also provide education and support to the client and family.

- Choice D: Physical therapist. This is correct because a physical therapist can help the client with mobility and balance issues. The client may have hemiparesis or hemiplegia, which is weakness or paralysis of one side of the body. The physical therapist can assist the client with exercises, gait training, and assistive devices to improve the client's functional status.

- Choice E: Chief nursing officer. This is incorrect because a chief nursing officer is not directly involved in the client's recovery. A chief nursing officer is a senior-level executive who oversees the nursing staff and operations of a health care organization. A chief nursing officer may have a role in quality improvement, policy development, and strategic planning, but not in individual client care.

- Choice F: Pharmacy technician. This is incorrect because a pharmacy technician is not directly involved in the client's recovery. A pharmacy technician is a health care professional who assists pharmacists with dispensing medications and other tasks. A pharmacy technician may have a role in preparing, labeling, and delivering medications, but not in providing therapy or education to the client.

- Choice G: Respiratory therapist. This is incorrect because a respiratory therapist is not directly involved in the client's recovery. A respiratory therapist is a health care professional who provides respiratory care to patients with breathing problems. A respiratory therapist may have a role in administering oxygen, nebulizers, ventilators, and other respiratory treatments, but not in addressing the client's stroke-related impairments.

- Choice H: Medical assistant. This is incorrect because a medical assistant is not directly involved in the client's recovery. A medical assistant is a health care professional who performs administrative and clinical tasks in a medical office or clinic. A medical assistant may have a role in scheduling appointments, taking vital signs, drawing blood, and performing basic laboratory tests, but not in providing rehabilitation or education to the client.

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Correct Answer is B

Explanation

Choice A reason: Obtaining a soft diet for the client is not the best initial nursing action for a client with chemotherapy-induced mucositis who is describing soreness of the tongue and oral issues. A soft diet can help reduce the irritation and discomfort of the oral mucosa, but it does not address the underlying cause of the inflammation and infection. The nurse should first assess the client's oral hygiene and provide appropriate interventions to prevent further complications.

Choice B reason: Encouraging frequent mouth care is the best initial nursing action for a client with chemotherapy-induced mucositis who is describing soreness of the tongue and oral issues. Frequent mouth care can help prevent or reduce the severity of mucositis by removing plaque, bacteria, and debris from the oral cavity, and by moisturizing and soothing the oral tissues. The nurse should instruct the client to use a soft toothbrush, a mild toothpaste, and a saline or bicarbonate rinse at least four times a day, and to avoid alcohol, tobacco, spicy, acidic, or hot foods and beverages.

Choice C reason: Cleansing the tongue and mouth with swabs is not the best initial nursing action for a client with chemotherapy-induced mucositis who is describing soreness of the tongue and oral issues. Swabs can be abrasive and damaging to the oral mucosa, especially if they are dry or contain alcohol or hydrogen peroxide. Swabs can also increase the risk of bleeding, infection, and ulceration of the oral tissues. The nurse should use a soft toothbrush or a gentle sponge to clean the tongue and mouth.

Choice D reason: Administering a topical analgesic per protocol is not the best initial nursing action for a client with chemotherapy-induced mucositis who is describing soreness of the tongue and oral issues. A topical analgesic can provide temporary relief of pain and discomfort, but it does not address the underlying cause of the inflammation and infection. The nurse should first assess the client's oral hygiene and provide appropriate interventions to prevent further complications. The nurse should also monitor the client's response to the analgesic and report any adverse effects or inadequate pain control.

A. Abdominal obesity. B. Blood pressure of 150/96 mm Hg. C. Elevated high density lipoproteins. D. Increased triglyceride levels. E. Hyperglycemia. F. Hypothyroidism.

Correct Answer is ["A","B","D","E"]

Explanation

Choice A reason: This is correct because abdominal obesity, also known as central obesity or visceral fat, is one of the criteria for diagnosing metabolic syndrome and a major risk factor for diabetes mellitus and vascular disease. Abdominal obesity is defined as having a waist circumference of more than 40 inches (102 cm) for men or 35 inches (88 cm) for women. Abdominal obesity can increase insulin resistance, inflammation, and blood pressure, which can lead to impaired glucose metabolism and cardiovascular complications.

Choice B reason: This is correct because blood pressure of 150/96 mm Hg is another criterion for diagnosing metabolic syndrome and a significant risk factor for diabetes mellitus and vascular disease. Blood pressure is defined as the force exerted by blood against the walls of blood vessels. Normal blood pressure is less than 120/80 mm Hg, while high blood pressure (hypertension) is 140/90 mm Hg or higher. High blood pressure can damage the blood vessels and organs, such as the heart, kidneys, eyes, and brain, and increase the risk of heart attack, stroke, kidney failure, and vision loss.

Choice C reason: This is incorrect because elevated high density lipoproteins (HDL), also known as good cholesterol, are not a criterion for diagnosing metabolic syndrome or a risk factor for diabetes mellitus and vascular disease. In fact, HDL are beneficial for cardiovascular health because they help remove excess cholesterol from the blood and prevent plaque buildup in the arteries. Normal HDL levels are 40 mg/dL (1.0 mmol/L) or higher for men and 50 mg/dL (1.3 mmol/L) or higher for women.

Choice D reason: This is correct because increased triglyceride levels are another criterion for diagnosing metabolic syndrome and a risk factor for diabetes mellitus and vascular disease. Triglycerides are a type of fat that circulates in the blood and provides energy to cells. Normal triglyceride levels are less than 150 mg/dL (1.7 mmol/L), while high triglyceride levels are 200 mg/dL (2.3 mmol/L) or higher. High triglyceride levels can increase insulin resistance, inflammation, and blood clotting, which can impair glucose metabolism and increase the risk of heart attack and stroke.

Choice E reason: This is correct because hyperglycemia, also known as high blood sugar, is another criterion for diagnosing metabolic syndrome and a hallmark of diabetes mellitus. Hyperglycemia occurs when the body cannot produce enough insulin or use it properly to regulate the amount of glucose in the blood. Normal blood glucose levels are 70 to 99 mg/dL (3.9 to 5.5 mmol/L) before meals and less than 140 mg/dL (7.8 mmol/L) two hours after meals, while hyperglycemia is 126 mg/dL (7.0 mmol/L) or higher before meals or 200 mg/dL (11.1 mmol/L) or higher two hours after meals. Hyperglycemia can damage the blood vessels and organs, such as the eyes, kidneys, nerves, and feet, and increase the risk of infections, ulcers, amputations, and diabetic ketoacidosis.

Choice F reason: This is incorrect because hypothyroidism, also known as underactive thyroid, is not a criterion for diagnosing metabolic syndrome or a direct risk factor for diabetes mellitus and vascular disease. Hypothyroidism occurs when the thyroid gland does not produce enough thyroid hormones, which regulate the body's metabolism, growth, and development. Hypothyroidism can cause symptoms such as fatigue, weight gain, cold intolerance, dry skin, hair loss, constipation, and depression. However, hypothyroidism does not affect the blood glucose or lipid levels directly, but rather indirectly through its effects on weight and appetite.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with chemotherapy-induced mucositis who is describing soreness of the tongue and oral issues. Which is the best initial nursing action?

Correct Answer is B

Explanation

The nurse prepares a teaching plan for an adult client with metabolic syndrome. Which finding(s) should the nurse address to help the client reduce the risk for diabetes mellitus and vascular disease? (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?

After teaching a client newly diagnosed with cholecystitis about recommended diet changes, the nurse evaluates the client's learning. Which food choices eliminated by the client indicate to the nurse that teaching has been successful?

Exhibits The triage nurse does a rapid assessment of the client. Which data indicates the client is in need of immediate health interventions?

A client who had a biliopancreatic diversion procedure (BPD) 3 months ago is admitted with severe dehydration. Which assessment finding warrants immediate intervention by the nurse?

A client with diabetes mellitus is admitted with an upper respiratory infection. Which changes in blood glucose management should the client expect?

Exhibits For each assessment finding, explain whether the actions taken were effective or ineffective.