A nurse is providing care for four patients. Which patient should the nurse evaluate first for cognitive impairment?
A 42-year-old patient with a serum sodium level of 134 mEq/L (134 mmol/L).
An 88-year-old patient who had a hemorrhagic stroke three days ago.
A patient who underwent an open cholecystectomy two days ago.
A 32-year-old patient with a 20-pack-year history of smoking.
The Correct Answer is B
Choice A rationale:
A serum sodium level of 134 mEq/L (134 mmol/L) is mildly low, but this level of hyponatremia is not typically associated with significant cognitive impairment.
Symptoms of hyponatremia, such as confusion, lethargy, and seizures, usually occur when sodium levels are 125 mEq/L or lower.
However, it's important to monitor this patient for any changes in cognitive status as hyponatremia can worsen and lead to more severe symptoms.
Choice C rationale:
A patient who underwent an open cholecystectomy two days ago may experience some cognitive impairment due to the effects of anesthesia and pain medications.
However, this type of impairment is usually temporary and resolves within a few days.
It's important to assess for cognitive impairment in this patient, but it is not the most urgent priority.
Choice D rationale:
A 32-year-old patient with a 20-pack-year history of smoking is at risk for cognitive impairment due to the long-term effects of smoking on the brain.
However, this risk is typically not as immediate as the risk of cognitive impairment following a stroke.
It's important to educate this patient about the risks of smoking and encourage smoking cessation, but it is not the most urgent priority in terms of cognitive assessment.
Choice B rationale:
An 88-year-old patient who had a hemorrhagic stroke three days ago is at the highest risk for cognitive impairment among the given options.
Hemorrhagic stroke involves bleeding in the brain, which can damage brain tissue and lead to cognitive deficits.
The risk of cognitive impairment is particularly high in older adults, as they may have less cognitive reserve to compensate for the damage caused by the stroke.
Early assessment and intervention for cognitive impairment are crucial for optimizing recovery and quality of life in stroke patients.
Prompt evaluation for cognitive impairment is essential to identify any deficits and initiate appropriate interventions to support the patient's cognitive function and recovery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Planning activities to prevent fatigue is a valid self-care strategy for SLE patients. Fatigue is a common symptom of SLE, and it can be exacerbated by overexertion. By planning activities and pacing themselves, patients can help to manage their fatigue and conserve energy.
Fatigue management strategies include:
Prioritizing tasks and delegating when possible.
Breaking down large tasks into smaller, more manageable ones. Taking frequent rest breaks throughout the day.
Maintaining a regular sleep schedule. Engaging in moderate exercise, as tolerated.
Avoiding caffeine and alcohol, which can interfere with sleep.
Addressing any underlying health conditions that may be contributing to fatigue, such as anemia or depression.
Choice B rationale:
Prioritizing rest is another essential self-care strategy for SLE patients. Rest allows the body to conserve energy and repair itself. Patients with SLE may need more rest than healthy individuals, especially during flares.
Resting strategies include:
Getting enough sleep at night. Napping during the day, as needed.
Taking breaks from activities throughout the day.
Practicing relaxation techniques, such as deep breathing or meditation.
Choice C rationale:
Sunbathing is not recommended for SLE patients, as it can trigger flares. Ultraviolet (UV) radiation from the sun can damage skin cells and exacerbate inflammation in SLE patients. This can lead to a flare-up of symptoms, such as skin rash, joint pain, and fatigue.
Sun protection strategies include:
Avoiding direct sunlight, especially during the middle of the day when UV rays are strongest. Wearing protective clothing, such as long-sleeved shirts, pants, and wide-brimmed hats.
Using sunscreen with an SPF of 30 or higher on a daily basis.
Applying sunscreen liberally and reapplying it every two hours, or more often if sweating or swimming.
Choice D rationale:
Avoiding direct sunlight is a correct self-care strategy for SLE patients.
Correct Answer is C
Explanation
Rationale:
Step 1: Divide the total volume of fluid (2000 ml) by the total time in hours (24 hours). Step 2: Perform the calculation: 2000 ml ÷ 24 hours = 83.33 ml/hour.
Step 3: Round the answer to the nearest whole number, as fluid administration is typically measured in whole milliliters.
The correct answer is 83 ml/hour.
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