A nurse is attending to a patient who suddenly experiences numbness and weakness on the right side of their body, including their arm and leg.

The nurse also observes a distinct droop on the right side of the patient’s face.

After reporting these findings to the healthcare provider, the nurse receives several prescriptions for the patient, including an immediate CT scan of the head.

What should be the nurse’s first course of action?

Initiate two large-bore IV catheters and review the inclusion criteria for IV fibrinolytic therapy.

Start continuous observation for transient episodes of neurologic dysfunction.

Elevate the head of the bed to 30 degrees, keeping the head and neck in neutral alignment.

Administer aspirin to prevent further clot formation and platelet aggregation.

Answer and Explanation

The Correct Answer is A

Choice A rationale
If a patient suddenly experiences numbness and weakness on the right side of their body, including their arm and leg, and a distinct droop on the right side of the patient’s face, these are warning signs of a stroke. The nurse’s first course of action should be to initiate two large- bore IV catheters and review the inclusion criteria for IV fibrinolytic therapy. This is because rapid administration of fibrinolytic therapy can significantly improve outcomes in patients with acute ischemic stroke.
Choice B rationale
Continuous observation for transient episodes of neurologic dysfunction is important, but the immediate priority is to prepare for potential fibrinolytic therapy.
Choice C rationale
Elevating the head of the bed to 30 degrees and keeping the head and neck in neutral alignment can be beneficial in certain situations, but it is not the immediate priority in this scenario.

Choice D rationale
Administering aspirin can help prevent further clot formation and platelet aggregation in patients with acute coronary syndrome or those at high risk of cardiovascular disease.
However, in the case of a suspected stroke, immediate medical evaluation and potential fibrinolytic therapy are the priorities.

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Correct Answer is A

Explanation

Choice A rationale

Inquiring about the frequency of falls in recent months is an important part of a functional assessment for an older adult patient reporting decreased strength in knees and handgrips. Falls can be a sign of decreased muscle strength and balance, which can be associated with aging and certain medical conditions.

Choice B rationale

Sundowning, or increased confusion and agitation in the late afternoon and evening, is a symptom often associated with dementia, not necessarily with decreased strength in knees and handgrips.

Choice C rationale

While discussing end-of-life care options is an important aspect of comprehensive patient care, it is not directly related to the patient’s reported symptoms of decreased strength.

Choice D rationale

Requesting the patient to lie as still as possible for the assessment may not provide comprehensive information about the patient’s functional mobility and strength.

A. Orange juice. B. Hot chocolate. C. Apple juice. D. Chicken broth.

Correct Answer is ["A","C","D"]

Explanation

Choice A rationale
Orange juice is a clear liquid and is allowed in the Mormon faith.

Choice B rationale
Hot chocolate is not a clear liquid and is not typically consumed by individuals who follow Mormon beliefs due to its caffeine content.
Choice C rationale
Apple juice is a clear liquid and is allowed in the Mormon faith.
Choice D rationale
Chicken broth is a clear liquid and is allowed in the Mormon faith.
Choice E rationale
Black coffee is not a clear liquid and is not typically consumed by individuals who follow Mormon beliefs due to its caffeine content.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult patient arrives at the clinic reporting decreased strength in knees and handgrips. What action should the nurse include in a functional assessment of this patient?

Correct Answer is A

Explanation

A client who follows Mormon beliefs is on a clear liquid diet following abdominal surgery. Which menu items should the nurse request for this client? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

A caregiver brings a client with end-stage Alzheimer’s disease to the clinic for an appointment with the healthcare provider. The caregiver confides in the nurse about experiencing sleepless nights and frequent bouts of crying. What action should the nurse take?

The nurse inspects the airway and finds no visible trauma, and the airway appears to be patent. What other assessment items are included in the primary survey? Select all that apply.

A mother rushes into the emergency department carrying her toddler who has been exposed to some cleaning products. The child has a chemical smell on their hands, face, and clothes. After ensuring the airway is patent, which action should the nurse take first?

An adolescent arrives at the emergency department (ED) with a fever and persistent lower right quadrant abdominal pain. The patient is anxious, fearful, and hyperventilating. What acid-base imbalance does the nurse anticipate the patient will develop?

The nurse is educating a patient who was admitted with a blood glucose level of 580 mg/dL on how to prevent complications related to diabetes mellitus. Which statement, if made by the patient, would indicate that they have understood the teaching?