A patient is hospitalized poststroke. The nurse approaches the patient from the patient's left side to provide morning care. The patient is staring straight ahead and does not respond to the nurse's presence or voice. Which action should the nurse take first?

Walk to the other side of the bed and try again.

Wave a hand in front of the patient's face.

Speak more loudly and clearly.

Use a picture board to explain to the patient what the nurse is going to do.

Answer and Explanation

The Correct Answer is A

A. Walk to the other side of the bed and try again: The patient may have right-sided neglect due to the stroke, meaning they are not aware of stimuli on the left side. Approaching from the other side where the patient has better perception might help them respond better.
B. Wave a hand in front of the patient's face: This might not be effective and can startle the patient. It does not address the underlying issue of spatial neglect.
C. Speak more loudly and clearly: There is no indication that the patient has hearing loss or language comprehension issues. Speaking louder may not be effective if the patient is experiencing spatial neglect.
D. Use a picture board to explain to the patient what the nurse is going to do: This is a good strategy for communication but does not address the immediate need to reposition to a more effective approach to gain the patient’s attention first.

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Correct Answer is A

Explanation

A. Uric acid: Elevated uric acid levels are the hallmark of gout and are used to monitor and diagnose the condition. Managing uric acid levels is crucial to prevent gout attacks.
B. Blood urea nitrogen: This is more related to kidney function and not directly relevant to gout.
C. Creatinine: Also related to kidney function. While kidney function is important in gout patients, uric acid levels are more directly related to gout management.
D. Cholesterol: High cholesterol is a cardiovascular risk but is not directly related to gout. Monitoring cholesterol is important but not the primary focus for gout management.

A. Keep affected body areas covered at all times. B. Avoid stimulation that causes vasoconstriction. C. Get plenty of outdoor exercise all year. D. Take vasopressors to prevent exacerbation of symptoms.

Correct Answer is B

Explanation

A. Keep affected body areas covered at all times: While keeping warm can help prevent attacks, it is not practical or necessary to cover the areas all the time, especially in warmer environments.
B. Avoid stimulation that causes vasoconstriction: Raynaud disease is triggered by factors that cause vasoconstriction, such as exposure to cold or stress. Avoiding these triggers is key to preventing attacks.
C. Get plenty of outdoor exercise all year: Exercise is beneficial for general health but exposure to cold during outdoor activities can trigger Raynaud's attacks, especially in cold weather.
D. Take vasopressors to prevent exacerbation of symptoms: Vasopressors cause vasoconstriction and would likely worsen Raynaud's symptoms rather than preventing them.

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A patient is hospitalized poststroke. The nurse approaches the patient from the patient's left side to provide morning care. The patient is staring straight ahead and does not respond to the nurse's presence or voice. Which action should the nurse take first?

Nursing Test Bank

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The nurse is caring for Mr. Able, age 46, who has gout. Which of these morning laboratory values does the nurse monitor for this patient?

Correct Answer is A

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Correct Answer is B

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