A nurse is assessing a client who has left-sided weakness following a stroke. Which of the following findings is the nurse's priority?

The client is consuming 25% of their meals.

The client coughs frequently while eating.

The client's blood pressure is 142/94 mm Hg.

The client leans to the left side while sitting.

Answer and Explanation

The Correct Answer is B

A. The client is consuming 25% of their meals.

Poor nutritional intake can lead to complications over time, but it is not the most immediate concern compared to other options. This finding is important but not the highest priority.

B. The client coughs frequently while eating.

Frequent coughing while eating can indicate dysphagia (difficulty swallowing), which increases the risk of aspiration. Aspiration can lead to serious complications like aspiration pneumonia, which is life-threatening. This is the nurse’s priority finding because it poses an immediate risk to the client’s airway and respiratory status.

C. The client's blood pressure is 142/94 mm Hg.

The blood pressure is elevated, which is concerning, especially in a post-stroke client. However, it is not critically high and does not present an immediate threat compared to the risk of aspiration.

D. The client leans to the left side while sitting.

Leaning to the left side while sitting could indicate poor balance or proprioception, which increases the risk of falls. While important to address, it is not as immediately critical as the risk of aspiration.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","F"]

Explanation

Correct responses

A. Lactose intolerant: Lactose intolerance can lead to lower dairy intake, which may reduce calcium intake, increasing the risk of osteoporosis.

B. Alcohol use: Excessive alcohol consumption can interfere with calcium absorption and bone health, increasing the risk of osteoporosis.

C. Smoking history: Smoking is associated with decreased bone density and increased risk of osteoporosis due to its negative effects on bone metabolism.

F. Vitamin D level: The client's vitamin D levels are below the recommended range. Vitamin D is crucial for calcium absorption and bone health, so insufficient levels can increase the risk of osteoporosis.

The other factors are less directly related to osteoporosis risk in this client:

D. Phosphorous level: The phosphorous level is within the normal range and is not directly linked to osteoporosis risk.

E. Activity level: The activity level is not provided in the information; however, physical activity is generally important for bone health. If the client is sedentary, it could be a risk factor, but it's not specified here.

A. Endotracheal suctioning B. Urinary catheter care C. Enteral feeding D. Wound Irrigation

Correct Answer is A

Explanation

A. Endotracheal suctioning:

This is the correct answer. If a client requires endotracheal suctioning, it is likely due to respiratory distress or compromised airway clearance. Ensuring a patent airway and maintaining adequate oxygenation is the top priority, making endotracheal suctioning the first procedure to be performed.

B. Urinary catheter care:

Urinary catheter care is important for preventing infections and maintaining urinary function, but it is generally not as urgent as addressing respiratory distress. If the client is experiencing respiratory issues, addressing these concerns should take precedence.

C. Enteral feeding:

While enteral feeding is essential for providing nutrition, it is not typically as urgent as addressing respiratory needs. If a client requires endotracheal suctioning for respiratory support, it should be prioritized over enteral feeding.

D. Wound irrigation:

Wound irrigation is important for wound care, but it is generally not as time-sensitive as addressing respiratory needs. If the client's airway is compromised, it takes precedence over wound irrigation.

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A nurse is assessing a client who has left-sided weakness following a stroke. Which of the following findings is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a provider's office is caring for a client. Exhibits The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for osteoporosis? (Select all that apply.)

Correct Answer is ["A","B","C","F"]

Explanation

A nurse is prioritizing care for a client. Which of the following procedures should the nurse perform first?

Correct Answer is A

Explanation

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