A patient presents to the emergency department (ED) complaining of nausea, vomiting, and the “worst headache he has ever experienced.”. While examining the patient, the nurse notes left leg and arm weakness.

The patient is immediately sent to the radiology department for a CT scan.

The registered nurse (RN) identifies the immediate need for treatment because:

A hemorrhagic brain attack is more common than an ischemic brain attack.

A thrombolytic drug will cause the peripheral and central reflexes to become hyper-reactive.

A hemorrhagic brain attack requires immediate intervention to prevent further damage.

An ischemic brain attack is less severe than a hemorrhagic brain attack.

Answer and Explanation

The Correct Answer is C

Choice A rationale
A hemorrhagic brain attack (stroke) is less common than an ischemic brain attack. Ischemic strokes account for the majority of strokes.
Choice B rationale
Thrombolytic drugs are used to treat ischemic strokes, not hemorrhagic strokes. They do not cause hyper-reactive reflexes.
Choice C rationale
A hemorrhagic brain attack requires immediate intervention to prevent further damage. Hemorrhagic strokes involve bleeding in the brain, which can rapidly worsen and cause severe damage.
Choice D rationale
An ischemic brain attack is not necessarily less severe than a hemorrhagic brain attack. Both types of strokes are serious, but hemorrhagic strokes often require more urgent intervention due to the risk of ongoing bleeding.

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Correct Answer is A

Explanation

Choice A rationale
Acute pancreatitis is characterized by severe epigastric pain and elevated levels of amylase and lipase. These enzymes are released into the bloodstream when the pancreas is inflamed, making acute pancreatitis the most likely diagnosis.
Choice B rationale
Acute hematochezia refers to the passage of fresh blood through the anus, usually in or with stools. It is not associated with elevated amylase and lipase levels or severe epigastric pain.
Choice C rationale
Left heart failure can cause symptoms such as shortness of breath and fluid retention, but it does not typically cause elevated amylase and lipase levels or severe epigastric pain.
Choice D rationale
Chronic hepatic failure involves long-term liver damage and may present with jaundice, ascites, and other symptoms. It is not associated with elevated amylase and lipase levels or severe epigastric pain.

A. Administer diuretic medication as prescribed. B. Elevate the client’s legs to reduce swelling. C. Assess the client’s respiratory status and oxygen saturation. D. Restrict fluid intake to prevent fluid overload.

Correct Answer is C

Explanation

Choice A rationale
Administering diuretic medication as prescribed is an important intervention for managing fluid overload in heart failure. Diuretics help reduce fluid accumulation by increasing urine output, which can alleviate symptoms such as swelling and shortness of breath. However, before administering any medication, it is crucial to assess the client’s current respiratory status and oxygen saturation to determine the severity of their condition and ensure that the intervention is appropriate and safe.
Choice B rationale
Elevating the client’s legs can help reduce swelling in the lower extremities by promoting venous return and decreasing fluid accumulation. While this intervention can provide some relief, it does not address the immediate concern of the client’s respiratory status. Assessing the client’s respiratory status and oxygen saturation is a priority to ensure that they are receiving adequate oxygenation and to identify any potential respiratory distress that may require urgent intervention.
Choice C rationale
Assessing the client’s respiratory status and oxygen saturation is the first priority in this scenario. Heart failure can lead to pulmonary congestion and impaired gas exchange, resulting in shortness of breath and decreased oxygen levels. By assessing the client’s respiratory status and oxygen saturation, the nurse can determine the severity of the client’s condition, identify any immediate respiratory needs, and implement appropriate interventions to improve oxygenation and respiratory function.
Choice D rationale
Restricting fluid intake is a common intervention for managing fluid overload in heart failure. By limiting fluid intake, the nurse can help prevent further fluid accumulation and reduce the risk of worsening symptoms. However, this intervention does not address the immediate concern of the client’s respiratory status. Assessing the client’s respiratory status and oxygen saturation is a priority to ensure that they are receiving adequate oxygenation and to identify any potential respiratory distress that may require urgent intervention.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient presents to his healthcare provider with complaints of severe epigastric pain. His lab work reveals high amylase and lipase levels. His diagnosis is most likely which condition?

Correct Answer is A

Explanation

A client with heart failure is experiencing shortness of breath and swelling in the lower extremities. Which of the following interventions should the nurse implement first?

Correct Answer is C

Explanation

A nurse is caring for a client with chronic kidney disease (CKD) who presents with hyperkalemia. Which of the following interventions should the nurse implement first?

Which acute event is most likely to occur in a patient who has chronic atrial fibrillation?

A registered nurse (RN) is providing strategies for “better breathing” to a patient with emphysema. Successful teaching of this topic would be identified when the patient states that he will:

A nurse is assessing a client who presents with a temperature of 38°C (100.4°F), a heart rate of 110 beats per minute, and a blood pressure of 90/60 mmHg.Which condition is the client most likely experiencing?

A nurse is assessing a client with a temperature of 39°C (102.2°F) and a blood pressure of 90/60 mmHg. Which condition is the client most likely experiencing?

A client presents with a temperature of 38°C (100.4°F) and a stiff neck. Which condition should the nurse suspect?

A nurse is caring for a client with a history of hypertension who presents with a severe headache and blurred vision. What is the most likely cause of these symptoms?