Exhibits

Complete the diagram by choosing from the choices below to specify which condition the client is most likely experiencing, two actions the nurse should take to address the condition, and two parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Condition: Transient ischemic stroke (d)

2 actions:

Request a prescription for a computerized tomography (CT) scan of the client's head and neck (d)
Perform a National Institute of Health Stroke Scale (NIHSS) assessment (e)

2 parameters:

Neurological status (a)
Blood pressure (c)

Rationale for correct condition: A transient ischemic stroke (TIA) is a temporary period of symptoms similar to those of a stroke and is often a precursor to a full-blown stroke. The patient's symptoms of dizziness, weakness, and a horrible headache, combined with his history of hypertension and atrial fibrillation, suggest a high risk for a TIA. The patient's confusion about the date and time also supports this condition. Immediate assessment and intervention are crucial to prevent a possible stroke.

Rationale for the two correct actions:

Request a prescription for a CT scan: This is essential to identify any blockages or abnormalities in the blood vessels of the brain, confirming the presence and extent of a TIA or stroke.
Perform an NIHSS assessment: This standardized tool is used to evaluate the severity of a stroke and to monitor changes in the patient's neurological status over time.

Rationale for parameters to monitor:

Neurological status: Monitoring this parameter helps track changes in the patient's cognitive and motor functions, which are critical in assessing the progression or improvement of the stroke symptoms.
Blood pressure: Hypertension is a major risk factor for strokes. Keeping a close watch on the blood pressure helps in managing and reducing the risk of further complications.

Rationale for incorrect conditions:

Hypoglycemia: While it can cause dizziness and weakness, the patient's recent UTI and headache are not typical for hypoglycemia.
Hemorrhagic stroke: This would typically present with more severe neurological symptoms and possible loss of consciousness.
Urinary tract infection: The patient's symptoms go beyond those of a UTI, especially given the headache, dizziness, and confusion.

Rationale for incorrect actions to take:

Administer 0.9% sodium chloride IV: Not specific to stroke management and doesn't address the immediate risk.
Administer oxygen via nasal cannula: The patient's oxygen saturation is normal; thus, this is not immediately necessary.
Request a prescription for the client's home medication of aspirin: While aspirin is used for stroke prevention, administering it without confirming the stroke type (ischemic vs hemorrhagic) could be harmful.

Rationale for incorrect parameters to monitor:

Respiratory rate: This is not directly related to stroke assessment.
Urine output: Irrelevant to the immediate management of TIA.
Oxygen saturation: The patient's oxygen levels are normal, so monitoring it won't provide further insights.

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Correct Answer is B

Explanation

Choice A reason: Jugular vein distension is often associated with right-sided heart failure, where the right ventricle fails to pump effectively, leading to increased pressure in the veins and fluid backup. While it can occur in advanced cases of left ventricular dysfunction, it is not as directly indicative as lower extremity edema.

Choice B reason: Lower extremity edema is a common finding in left ventricular dysfunction. When the left ventricle fails to pump blood efficiently, it leads to a buildup of fluid in the lungs and eventually in the extremities. This results in swelling, particularly in the lower legs and feet. This symptom is a key indicator of congestive heart failure.

Choice C reason: Hepatomegaly, or enlargement of the liver, is more commonly associated with right-sided heart failure due to congestion of blood flow in the liver. While it can occur in severe cases of left ventricular dysfunction, it is not as typical an initial finding as lower extremity edema.

Choice D reason: Fatigue is a non-specific symptom that can be associated with various conditions, including heart failure. However, it is not as immediately indicative of left ventricular dysfunction as lower extremity edema, which is more directly related to the underlying issue of fluid retention and heart failure.

A. Complete blood count B. Platelet count C. Serum electrolytes D. Liver enzymes

Correct Answer is A

Explanation

Choice A reason: A complete blood count (CBC) is the most relevant laboratory value to review for a client with iron deficiency anemia who reports increased fatigue. The CBC will provide important information about the levels of red blood cells, hemoglobin, and hematocrit, which are directly affected by iron deficiency. Monitoring these values will help determine if the client’s anemia is worsening or if the iron supplements are not effectively improving the blood count.

Choice B reason: The platelet count is part of a CBC but is not directly related to the symptoms of fatigue in iron deficiency anemia. While platelet levels are important for assessing clotting function, they do not provide the necessary information about red blood cell levels or hemoglobin concentration that are central to diagnosing and managing anemia.

Choice C reason: Serum electrolytes are important to monitor for overall health and hydration status, but they are not specifically related to the client’s anemia or the symptom of fatigue. Electrolyte imbalances typically do not cause fatigue related to anemia, so this is not the primary laboratory value to review in this context.

Choice D reason: Liver enzymes are important for assessing liver function and potential liver damage, but they are not directly related to iron deficiency anemia or the symptom of fatigue. While it is important to monitor liver health, especially if the client is on medications that affect the liver, the complete blood count is more relevant to the symptoms described.

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Exhibits Complete the diagram by choosing from the choices below to specify which condition the client is most likely experiencing, two actions the nurse should take to address the condition, and two parameters the nurse should monitor to assess the client's progress.

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Naxlex Comprehensive Predictor Exams

An adult client newly diagnosed with left ventricular dysfunction is admitted to the hospital with fine rales and wheezing. When assessing this client, which additional finding is the nurse likely to obtain?

Correct Answer is B

Explanation

A client who takes daily supplemental iron tablets for iron deficiency anemia reports feeling increasingly fatigued. Which laboratory value should the nurse review?

Correct Answer is A

Explanation

Exhibits Complete the diagram by choosing from the choices below to specify which condition the client is most likely experiencing, two actions the nurse should take to address the condition, and two parameters the nurse should monitor to assess the client's progress.

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Exhibits After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.

Exhibits

Complete the diagram by choosing from the choices below to specify which condition the client is most likely experiencing, two actions the nurse should take to address the condition, and two parameters the nurse should monitor to assess the client's progress.