A patient is admitted to the hospital with symptoms consistent with a right hemisphere stroke. Which neurovascular assessment requires immediate intervention by the nurse?

Pupillary changes to ipsilateral dilation.

Left-sided facial drooping and dysphagia.

Orientation to person and place only.

Unequal bilateral hand grip strengths.

Answer and Explanation

The Correct Answer is A

Choice A reason: Pupillary changes to ipsilateral dilation indicate increased intracranial pressure, which is a life-threatening complication of stroke. The nurse should notify the physician and prepare for emergency measures.

Choice B reason: Left-sided facial drooping and dysphagia are common signs of right hemisphere stroke, but they do not require immediate intervention by the nurse. The nurse should monitor the patient's swallowing ability and provide oral care.

Choice C reason: Orientation to person and place only is a sign of impaired cognition, which is also common in right hemisphere stroke. The nurse should assess the patient's memory, judgment, and attention span.

Choice D reason: Unequal bilateral hand grip strengths are a sign of hemiparesis, which is a weakness on one side of the body. The nurse should assist the patient with mobility and prevent contractures.

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Correct Answer is C

Explanation

Choice A: A headache rated at 0 on 0 to 10 scale is not a specific indicator of the effectiveness of an antihistamine. A headache may be caused by other factors, such as dehydration, stress, or sinus congestion.

Choice B: Oxygen saturation level of 99% is a normal finding and does not reflect the effect of an antihistamine. Oxygen saturation measures the amount of oxygen in the blood and can be affected by respiratory conditions, altitude, or smoking.

Choice C: Ambulating easily without vertigo is a sign that the antihistamine is effective. Vertigo is a common symptom of Ménière's disease, which is a disorder of the inner ear that causes episodes of spinning sensation, hearing loss, and tinnitus. Antihistamines can help reduce the fluid buildup in the inner ear and relieve vertigo.

Choice D: Blood pressure of 120/80 mm Hg is a normal finding and does not indicate the effect of an antihistamine. Blood pressure measures the force of blood against the walls of the arteries and can be influenced by factors such as heart rate, cardiac output, blood volume, and vascular resistance.

A. Measure capillary glucose level. B. Encourage ambulation in the room. C. Monitor for bloody diarrheal stools. D. Obtain vital sign measurements.

Correct Answer is D

Explanation

Choice A reason: Measuring capillary glucose level is not a priority action for a client with a rigid abdomen and rebound tenderness. These signs indicate peritonitis, which is a serious complication of IBD that requires immediate attention. Corticosteroids can increase blood glucose levels, but this is not an urgent concern in this situation.

Choice B reason: Encouraging ambulation in the room is not appropriate for a client with a rigid abdomen and rebound tenderness. These signs indicate peritonitis, which is a serious complication of IBD that requires immediate attention. Ambulation can worsen the pain and inflammation, and increase the risk of bowel perforation.

Choice C reason: Monitoring for bloody diarrheal stools is important for a client with IBD, but not a priority action for a client with a rigid abdomen and rebound tenderness. These signs indicate peritonitis, which is a serious complication of IBD that requires immediate attention. Bloody stools can be a sign of ulceration or bleeding in the bowel, but they are not specific to peritonitis.

Choice D reason: Obtaining vital sign measurements is the priority action for a client with a rigid abdomen and rebound tenderness. These signs indicate peritonitis, which is a serious complication of IBD that requires immediate attention. Vital signs can reveal signs of infection, inflammation, shock, and organ failure, which can guide the appropriate interventions and treatments.

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A patient is admitted to the hospital with symptoms consistent with a right hemisphere stroke. Which neurovascular assessment requires immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient experiences residual effects following an acute attack of Ménière's disease and receives a new prescription for an antihistamine. Which assessment finding indicates that the medication is effective?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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