A patient with heart failure has met with their primary provider and begun treatment with an angiotensin-converting enzyme (ACE) inhibitor. When the patient begins treatment, which assessment should the nurse prioritize?

Oxygen saturation.

Blood pressure.

Level of consciousness.

Assessment for nausea.

Answer and Explanation

The Correct Answer is B

When a patient with heart failure begins treatment with an ACE inhibitor, the nurse should prioritize monitoring the patient's blood pressure because ACE inhibitors can cause hypotension. Oxygen saturation, choice A, may be important to monitor in some cases, but it is not the priority in this situation. Level of consciousness, choice C, and assessment for nausea, choice D, may also be important but are not the priority assessments in this situation.

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Correct Answer is C

Explanation

Altered level of consciousness (LOC). Increased ICP can cause decreased LOC or changes in mental status, including confusion, agitation, or coma.

Options A, amnesia, and B, tachycardia, are not necessarily indicative of increased ICP, while option D, hypotension, is actually a sign of decreased ICP. Monitoring for elevated ICP is critical in patients with traumatic brain injury, and early recognition and intervention can be lifesaving. The nurse should report any changes in the patient's level of consciousness or other neurological symptoms to the provider immediately.

A. Manipulating and controlling others' behavior. B. Decreasing anxiety to a tolerable level. C. Limiting the amount of time available for interaction with others. D. Focusing attention on useful tasks.

Correct Answer is B

Explanation

In clients with obsessive-compulsive disorder (OCD), cleaning and organizing can be a way of decreasing anxiety to a tolerable level. This behavior is a compulsive behavior that is often related to the individual's obsessions. It is not an attempt to manipulate or control others, limit interaction with others, or focus attention on useful tasks.

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A patient with heart failure has met with their primary provider and begun treatment with an angiotensin-converting enzyme (ACE) inhibitor. When the patient begins treatment, which assessment should the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?

Correct Answer is C

Explanation

A nurse is caring for a client who has obsessive-compulsive disorder (OCD) and is constantly picking up after others and cleaning in the day room. The nurse should recognize the client's actions as which of the following?

Correct Answer is B

Explanation

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