A client is admitted to the hospital with symptoms consistent with a right hemisphere stroke. Which neurovascular assessment requires immediate intervention by the nurse?

Orientation to person and place only.

Unequal bilateral hand grip strengths.

Left-sided facial drooping and dysphagia.

Pupillary changes to ipsilateral dilation.

Answer and Explanation

The Correct Answer is D

Choice A reason: Orientation to person and place only suggests confusion, common in right hemisphere stroke affecting non-dominant cognition. This is not immediately life-threatening. Pupillary dilation indicates increased intracranial pressure (ICP) or herniation, a critical emergency requiring urgent intervention to prevent brain stem damage or death.

Choice B reason: Unequal hand grip strengths indicate hemiparesis, typical in right hemisphere stroke affecting left-sided motor function. This is expected and not acutely life-threatening. Pupillary dilation signals rising ICP or herniation, necessitating immediate intervention to prevent catastrophic neurological decline, making it the priority finding.

Choice C reason: Left-sided facial drooping and dysphagia are common in right hemisphere stroke, reflecting contralateral cranial nerve deficits. These are serious but not immediately life-threatening. Pupillary dilation indicates potential herniation from ICP, requiring urgent intervention like mannitol to prevent brain stem compression and fatal outcomes.

Choice D reason: Ipsilateral pupillary dilation in right hemisphere stroke signals increased ICP or herniation, compressing the oculomotor nerve (CN III), impairing pupillary constriction. This life-threatening emergency indicates impending brain stem compromise, requiring immediate intervention with ICP-lowering measures or surgery to prevent irreversible damage or death.

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Correct Answer is A

Explanation

Choice A reason: Starting the collection time after emptying the bag ensures an accurate 24-hour urine sample, critical for diagnostic tests like creatinine clearance. This defines the collection period, per laboratory and diagnostic specimen collection protocols in nursing practice.

Choice B reason: Catheter care prevents infection but is not the most critical step for initiating a 24-hour collection. Starting the collection time ensures accurate timing, essential for valid results, per urinary specimen collection and infection control standards in nursing.

Choice C reason: Clamping the catheter is inappropriate, as it disrupts continuous urine flow, skewing the 24-hour collection. Starting the collection time ensures accurate sampling, critical for diagnostic accuracy, per urinary catheter management and laboratory protocols in nursing practice.

Choice D reason: Labeling the container is important but secondary to starting the collection time, which defines the 24-hour period for accurate results. Timing ensures valid diagnostic data, per specimen collection and laboratory standards in nursing practice for urine collections.

A. Protein and albumin. B. Complete blood count (CBC). C. BUN and creatinine. D. Electrolytes.

Correct Answer is B

Explanation

Choice A reason: Protein and albumin reflect nutritional or liver status but are unaffected by enoxaparin, a low-molecular-weight heparin inhibiting factor Xa. These do not monitor anticoagulation effects or complications like bleeding. CBC is critical, as enoxaparin increases bleeding risk, requiring platelet and hemoglobin monitoring to detect serious hematological issues.

Choice B reason: Enoxaparin, an anticoagulant, heightens bleeding risk and can cause thrombocytopenia. Monitoring CBC, especially platelets and hemoglobin, detects heparin-induced thrombocytopenia (HIT) or hemorrhage. This ensures early identification of complications, allowing timely intervention to prevent severe bleeding or thrombosis, making CBC the most critical test for safe administration.

Choice C reason: BUN and creatinine assess renal function, relevant for renally cleared drugs, but enoxaparin is primarily liver-metabolized. Renal monitoring is secondary unless severe impairment exists. CBC is more urgent, as enoxaparin’s anticoagulant effect increases bleeding risk, necessitating hematological surveillance to prevent life-threatening complications.

Choice D reason: Electrolytes like potassium or sodium are not directly affected by enoxaparin’s action on the coagulation cascade. Imbalances may occur in critical illness but are not primary concerns. CBC monitoring for bleeding or thrombocytopenia is critical, as enoxaparin’s anti-Xa activity poses hematological risks requiring immediate attention.

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A client is admitted to the hospital with symptoms consistent with a right hemisphere stroke. Which neurovascular assessment requires immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is initiating a 24-hour urine collection for a client with an indwelling urinary catheter. After emptying all the urine from the collection bag, which action is most important for the nurse to implement?

Correct Answer is A

Explanation

Which serum laboratory test is most important for the nurse to monitor when administering enoxaparin to a client?

Correct Answer is B

Explanation

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