A nurse enters the room of a client and discovers the client with new right-sided weakness and slurred speech. Which of the following actions should the nurse take?

Perform carotid massage.

Call for help.

Provide the client with water to test the gag reflex.

Administer thrombolytics.

Answer and Explanation

The Correct Answer is B

Choice A reason: Performing carotid massage is not an appropriate action for a nurse to take when a client has signs of a stroke, as it may worsen the condition or cause complications. Carotid massage is a technique that involves applying pressure to the carotid artery in the neck to stimulate the vagus nerve and slow down the heart rate. It is used to treat some types of arrhythmias, such as supraventricular tachycardia. However, carotid massage may dislodge a blood clot or plaque from the carotid artery and cause an embolic stroke, which is a type of ischemic stroke that occurs when a blood clot travels to the brain and blocks a blood vessel. Carotid massage may also cause bradycardia, hypotension, or syncope, which can reduce the blood flow to the brain and worsen the ischemic damage.

Choice B reason: Calling for help is an appropriate action for a nurse to take when a client has signs of a stroke, as it initiates the emergency response and allows for prompt evaluation and treatment. Stroke is a medical emergency that occurs when the blood supply to a part of the brain is interrupted, causing brain cells to die. The sooner the stroke is recognized and treated, the better the chances of survival and recovery. Therefore, the nurse should call for help as soon as possible and activate the stroke protocol in the facility.

Choice C reason: Providing the client with water to test the gag reflex is not an appropriate action for a nurse to take when a client has signs of a stroke, as it may cause aspiration or choking. A gag reflex is an involuntary contraction of the throat muscles that prevents foreign objects from entering the airway. It is tested by touching the back of the throat with a tongue depressor or a cotton swab. However, this test is not indicated in a client who has signs of a stroke, as it may trigger vomiting or coughing, which can increase intracranial pressure or cause bleeding. Moreover, giving water to a client who has signs of a stroke may be dangerous, as they may have dysphagia (difficulty swallowing) or facial weakness, which can impair their ability to swallow safely and increase the risk of aspiration pneumonia.

Choice D reason: Administering thrombolytics is not an appropriate action for a nurse to take when a client has signs of a stroke, as it may be contraindicated or harmful depending on the type and timing of the stroke. Thrombolytics are medications that dissolve blood clots and restore blood flow. They are used to treat ischemic stroke, which is caused by a blood clot that blocks a blood vessel in the brain. However, thrombolytics are not effective for hemorrhagic stroke, which is caused by bleeding into or around the brain. In fact, thrombolytics may worsen hemorrhagic stroke by increasing bleeding and intracranial pressure. Therefore, thrombolytics should only be given after confirming the type of stroke by imaging tests such as computed tomography (CT) scan or magnetic resonance imaging (MRI). Thrombolytics should also be given within a specific time window after the onset of symptoms, usually within 3 to 4.5 hours, as they may lose their effectiveness or cause complications if given too late. Therefore, administering thrombolytics is not an action that a nurse can take without proper assessment and orders from the health care provider.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A: Encourage community members to practice fire drills. This is incorrect because fire drills are a part of the preparedness phase, not the prevention/mitigation phase. The prevention/mitigation phase aims to reduce the risk and impact of disasters, while the preparedness phase aims to enhance the readiness and response capacity of individuals and communities.

Choice B: Identify community members who have disabilities. This is incorrect because identifying community members who have disabilities is also a part of the preparedness phase, not the prevention/mitigation phase. The prevention/mitigation phase focuses on actions that can prevent or minimize the occurrence or effects of disasters, such as installing smoke detectors, reinforcing buildings, or creating evacuation routes.

Choice C: Provide first aid to community members affected by a tornado. This is incorrect because providing first aid to community members affected by a tornado is a part of the response phase, not the prevention/mitigation phase. The response phase involves immediate actions to save lives, protect property, and meet basic needs after a disaster occurs.

Choice D: Assist community members in developing a disaster plan. This is correct because assisting community members in developing a disaster plan is a part of the prevention/mitigation phase. A disaster plan can help identify potential hazards, assess vulnerabilities, establish goals and objectives, and implement strategies to reduce the risk and impact of disasters.

A. A negative-pressure isolation room B. A positive-pressure isolation room C. A private room D. A semi-private room with a client who has pediculosis capitis

Correct Answer is C

Explanation

Choice A reason: A negative-pressure isolation room is not a suitable room for a client who has scabies. A negative-pressure isolation room is used for clients who have airborne infections, such as tuberculosis or chickenpox. It prevents the contaminated air from escaping the room and infecting other people.

Choice B reason: A positive-pressure isolation room is not a suitable room for a client who has scabies. A positive-pressure isolation room is used for clients who have compromised immune systems, such as those undergoing bone marrow transplants or chemotherapy. It prevents the outside air from entering the room and exposing the client to germs.

Choice C reason: A private room is a suitable room for a client who has scabies. Scabies is a skin infection caused by tiny mites that burrow under the skin and cause intense itching and rash. Scabies can spread easily through direct skin-to-skin contact or sharing personal items, such as clothing or bedding. A private room can prevent the transmission of scabies to other clients or staff.

Choice D reason: A semi-private room with a client who has pediculosis capitis is not a suitable room for a client who has scabies. Pediculosis capitis is an infestation of head lice that feeds on human blood and causes itching and irritation on the scalp. Pediculosis capitis can also spread easily through direct contact or sharing personal items, such as combs or hats. Sharing a room with another client who has pediculosis capitis can increase the risk of cross-infection and complicate the treatment of both conditions.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse enters the room of a client and discovers the client with new right-sided weakness and slurred speech. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A community health nurse is assigned to identify activities that are a part of the prevention/mitigation phase of the disaster management cycle. Which of the following activities should the nurse identify as being in the prevention/mitigation phase?

Correct Answer is D

Explanation

A charge nurse is making a room assignment for a client who has scabies. In which of the following rooms should the nurse place the client?

Correct Answer is C

Explanation

A nurse is teaching a client who has a new prescription for sumatriptan (Imitrex) tablets to treat migraine headaches. Which of the following instructions should the nurse include?

A nurse is delegating tasks to the assistive personnel (AP). The nurse should direct the AP to complete which of the following tasks first?

A nurse is delegating tasks to assistive personnel. Which of the following should the nurse consider when using one of the five rights of delegation?

A nurse is using analytic epidemiology when conducting a research project on a comparison group. Which of the following research projects is the nurse most likely completing?

An occupational health nurse in the clinic of an industrial plant is developing a guidebook for clinic workers. Which of the following actions should the nurse include as a secondary prevention strategy?

The school nurse identified 12 students with confirmed cases of influenza A. The families of the children are advised to keep the children home for a minimum of 5 to 7 days. Which of the following is an appropriate action by the nurse?

A nurse is determining if a homebound client is eligible for Meals-on-Wheels. Which of the following is the most important factor for the nurse to consider?

The hospital's Emergency Operations Committee is working on their disaster plan. In which components should nurses be included? SELECT ALL THAT APPLY