A nurse is caring for a client who has had a stroke.

Exhibits

Select the 3 findings that require immediate follow-up.

Drooling

Blood pressure at 1800

Breath sounds at 1000

Hoarse voice

Temperature at 1800

Answer and Explanation

Correct Answer : A,D,E

A. Drooling
Drooling can be concerning due to impaired swallowing and risk of aspiration.
D. Hoarse voice
Hoarseness after swallowing can indicate aspiration, which is a serious complication for stroke patients due to difficulty swallowing.
E. Temperature at 1800
A temperature of 39.6°C (103.3°F) is significantly elevated and suggests a potential infection, which is a serious complication after a stroke

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Correct Answer is B

Explanation

A. The primary purpose of a halo fixation device is to immobilize the cervical spine to prevent further injury and promote healing.
B. The halo device provides rigid immobilization of the cervical spine.
C. This is incorrect and dangerous. The screws in the halo device should only be tightened by a healthcare professional.
D. Applying talcum powder under the halo vest can actually increase the risk of skin breakdown. The area should be kept clean and dry.

A. Hypotension B. Muscle pain C. Ototoxicity D. Hyperthermia

Correct Answer is A

Explanation

A. Verapamil, as a calcium channel blocker, can cause vasodilation (widening of blood vessels), which can lead to a decrease in blood pressure. Monitoring for hypotension is crucial when administering verapamil, especially via IV bolus, as it can rapidly lower blood pressure and potentially lead to symptoms such as dizziness, lightheadedness, or fainting.
B. Muscle pain is not a common or expected adverse effect of verapamil. While some medications might cause muscle-related symptoms, verapamil is more commonly associated with cardiovascular effects, such as hypotension and bradycardia, rather than muscle pain.
C. Ototoxicity is not a known adverse effect of verapamil. Ototoxicity is more commonly associated with other classes of drugs, such as certain antibiotics (e.g., aminoglycosides) or diuretics. Verapamil primarily affects the cardiovascular system, so ototoxicity is not a concern with this medication.
D. Hyperthermia is not a common adverse effect of verapamil. Verapamil does not typically affect body temperature regulation. Conditions associated with hyperthermia are more likely related to infections, overheating, or certain other medications, but not verapamil.

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A nurse is caring for a client who has had a stroke. Exhibits Select the 3 findings that require immediate follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make?

Correct Answer is B

Explanation

A nurse is preparing to administer verapamil by IV bolus to a client who is having cardiac dysrhythmias. For which of the following adverse effects should the nurse monitor when giving this medication?

Correct Answer is A

Explanation

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A nurse is caring for a client who has had a stroke.

Exhibits

Select the 3 findings that require immediate follow-up.