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Exhibits

Click to highlight the findings that require follow up.

Neurological: Alert and oriented. Agitated. Denies headaches.

Cardiovascular: Reported chest pain described as pressure and tightness that is unrelieved with rest. Rapid regular rhythm. Normal heart tones. Radial and pedal pulses 2+. Capillary refill 2 seconds.

Respiratory: Rapid and shallow breaths. Clear breath sounds throughout bilateral lungs.

Gastrointestinal: Within normal limits (WNL).

Genitourinary: WNL

Musculoskeletal: WNL

Pain: 7 on a 0 to 10 scale, tightness and pressure in chest. Started approximately 2 hours ago and got progressively worse, unrelieved by rest.

Alert and oriented

chest pain described as pressure and tightness that is unrelieved with rest

Radial and pedal pulses 2+

Capillary refill 2 seconds

Rapid and shallow breaths

Clear breath sounds throughout bilateral lungs

7 on a 0 to 10 scale, tightness and pressure in chest

Answer and Explanation

The Correct Answer is ["B","E","G"]

Chest pain described as pressure and tightness that is unrelieved with rest: Chest pain that is described as tightness and pressure, particularly when unrelieved by rest, is a classic presentation of acute coronary syndrome (ACS), which includes conditions such as unstable angina or myocardial infarction (MI). This is a red flag symptom, as it indicates a need for immediate medical attention to rule out life-threatening conditions like MI, which can be fatal without timely intervention.

Rapid shallow breaths: Rapid and shallow breathing can be a response to acute pain, particularly in a situation involving cardiovascular stress. It may be indicative of the body's attempt to compensate for inadequate oxygenation due to cardiac ischemia, hypoxia, or anxiety.

Pain 7/10, tightness and pressure in the chest: A pain rating of 7/10 demands immediate evaluation and management, as it could indicate an evolving cardiovascular event. Moreover, tightness and pressure are specific descriptors of pain seen in ischemic heart disease, where there is reduced blood flow to the heart muscle, leading to discomfort due to oxygen deprivation.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. While measuring body temperature is important for infection monitoring, it is not the primary concern after prasugrel administration.
B. Pedal edema is not a common side effect of prasugrel and does not directly relate to its adverse effects.
C. Prasugrel is an antiplatelet medication that increases the risk of bleeding. Monitoring for signs of bleeding, such as blood in the urine (hematuria), is important to assess for adverse effects.
D. Assessing skin turgor is important for hydration status but does not address bleeding risks associated with prasugrel.

A. Brain damage with CP is not progressive but does have a variable course. B. CP is one of the most common permanent physical disability in children. C. Continued development of the brain lesion determines the child's outcome D. Severe motor dysfunction determines the extent of successful habilitation.

Correct Answer is A

Explanation

A. Cerebral palsy is caused by brain injury or abnormal development, but the damage itself does not worsen over time. The severity of symptoms can vary as the child grows, but it is not progressive.

B. While CP is a permanent disability, this response does not address the client’s concern about the progression of symptoms.

C. The brain lesion in CP does not continue to develop in most cases, so this explanation would not provide accurate information.

D. Severe motor dysfunction does not solely determine the child’s outcome, as therapy and early interventions can significantly improve functional abilities.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this clients plan of care?

Correct Answer is C

Explanation

The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?

Correct Answer is A

Explanation

A client with hemorrhoids asks for information about a high fiber diet. Which breakfast menu item(s) should the nurse suggest? Select all that apply.

A client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant heart sounds, and is anxious and restless. After initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?

Patient Data Exhibits Which should the nurse immediately do? Select all that apply.

The nurse observes an unlicensed assistive personal (UAP) washing hands prior to entering the client's room. Which action by the UAP requires additional teaching?

The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which activity should the nurse assign to the UAP?

Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients?