A nurse is shopping and finds a woman who has collapsed with right-sided weakness and slurred speech.
Which of the following actions should the nurse take?

Call emergency medical services.

Find a location for the client to sit.

Drive the client to the nearest emergency room.

Obtain the number of the client's provider.

Answer and Explanation

The Correct Answer is A

The nurse should call emergency medical services if they find a woman who has collapsed with right-sided weakness and slurred speech. These symptoms could indicate a stroke or other serious medical condition that requires immediate medical attention.

Finding a location for the client to sit, driving the client to the nearest emergency room, and obtaining the number of the client's provider are not appropriate initial actions for the nurse to take in this situation. The priority is to get the client immediate medical attention by calling emergency medical services.

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Correct Answer is D

Explanation

A nurse collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm should monitor the client for hypertension as a manifestation of increased intracranial pressure. Increased intracranial pressure can cause changes in blood pressure, including hypertension.

a. Peripheral edema is not a manifestation of increased intracranial pressure. Peripheral edema is swelling in the extremities and can be caused by a variety of conditions.

b. Diarrhea is not a manifestation of increased intracranial pressure. Diarrhea is loose or watery stools and
can be caused by a variety of conditions.

c. Decreased pedal pulses are not a manifestation of increased intracranial pressure. Decreased pedal
pulses can indicate poor circulation to the feet and can be caused by a variety of conditions.

A. Presence of absence seizures B. Postictal phase C. Presence of automatisms D. Aura phase

Correct Answer is B

Explanation

The nurse should use the term "postictal phase" when documenting the client's difficulty arousing and sleepiness for several hours following a generalized tonic-clonic seizure. The postictal phase is the period of time immediately following a seizure during which the client may be difficult to arouse and very sleepy.

Presence of absence seizures, presence of automatisms, and aura phase are not appropriate descriptions for the nurse to use when documenting this finding in the medical record. Absence seizures are a type of seizure characterized by brief episodes of staring and unresponsiveness. Automatisms are repetitive, unconscious movements that can occur during a seizure. The aura phase is a warning sign that can occur before a seizure.

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A nurse is shopping and finds a woman who has collapsed with right-sided weakness and slurred speech. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

Correct Answer is D

Explanation

A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record?

Correct Answer is B

Explanation

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A nurse is shopping and finds a woman who has collapsed with right-sided weakness and slurred speech.
Which of the following actions should the nurse take?