A nurse is performing an initial interview of a client who has a neurologic deficit. Which actions by the nurse are MOST appropriate? (SELECT ALL THAT APPLY)

Reassure the client that information they share with the nurse is confidential

Instruct that complementary therapies are rarely helpful

Assess physical appearance and gait

Review current medication list including dosage & frequency

Ask about current alcohol or drug use

Answer and Explanation

Correct Answer : A,C,D,E

A. Reassure the client that information they share with the nurse is confidential
Establishing trust and confidentiality is essential in a health interview, especially for clients with neurological deficits who may feel vulnerable.

B. Instruct that complementary therapies are rarely helpful
This statement is not evidence-based and may dismiss patient preferences. Some complementary therapies, such as physical therapy or mindfulness, can be helpful in neurological conditions.

C. Assess physical appearance and gait
Observing physical appearance and gait provides important clues about neurological deficits, such as weakness, ataxia, or tremors.

D. Review current medication list including dosage & frequency
Medication history is critical in neurological assessments, as certain medications (e.g., anticoagulants, anticonvulsants) can impact the client’s condition.

E. Ask about current alcohol or drug use
Alcohol and drug use can contribute to neurological impairment and should be assessed during the history-taking process.

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Correct Answer is ["A","E"]

Explanation

A. A
Patients with A- blood type have A antigens on their red blood cells and do not have the Rh factor (negative). They can receive A- blood because it has the same antigens and Rh factor, making it a perfect match.

B. O+
Rh-negative clients cannot receive Rh-positive blood, as it may trigger an immune reaction.

C. AB-
Type AB blood contains A and B antigens, which A- individuals do not naturally have, increasing the risk of a transfusion reaction.

D. A+
A Rh-negative (A-) client cannot receive Rh-positive (A+) blood due to the risk of Rh sensitization.

E. O-
O- blood is the universal donor for red blood cells, meaning it contains no A, B, or Rh antigens, making it safe for an A- recipient.

A. Color of conjunctiva B. Deep tendon reflexes C. IV Insertion site D. Blood pressure and heart rate E. Hourly urine output

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

Explanation

A. Color of conjunctiva
While assessing for signs of perfusion is important, conjunctival color is not a primary assessment for norepinephrine administration. Perfusion is better assessed through blood pressure, heart rate, capillary refill, and urine output.

B. Deep tendon reflexes
Norepinephrine primarily affects vascular tone and cardiac output. Deep tendon reflexes are not a priority assessment for this medication.

C. IV Insertion site
Norepinephrine is a vasopressor, and extravasation can cause severe tissue necrosis. Frequent monitoring of the IV site is necessary to prevent complications.

D. Blood pressure and heart rate
Norepinephrine increases blood pressure and heart rate through vasoconstriction. Continuous monitoring is required to assess for excessive hypertension, tachycardia, or inadequate response to therapy.

E. Hourly urine output
Urine output is an essential indicator of organ perfusion. Since norepinephrine is used to maintain adequate blood pressure and perfusion in septic shock, monitoring urine output helps assess the effectiveness of treatment.

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A nurse is performing an initial interview of a client who has a neurologic deficit. Which actions by the nurse are MOST appropriate? (SELECT ALL THAT APPLY)

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Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer a unit of packed red blood cells (PRBC's) to a patient whose blood type is A- (negative). The nurse knows that this patient can receive transfusions from which blood types? (Select All that Apply)

Correct Answer is ["A","E"]

Explanation

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

Explanation

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