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: Notifying the surgical team to cancel the surgery is premature without confirming the pregnancy status. While it is critical to consider the possibility of pregnancy before surgery, the decision to cancel should be based on confirmed information rather than a possibility.

Choice B reason: Performing a bedside pregnancy test is the most appropriate immediate intervention. This test can provide rapid confirmation of pregnancy status. If the client is pregnant, the surgical team can then evaluate the risks and benefits of proceeding with or postponing the surgery. Immediate confirmation helps guide clinical decision-making and ensures the safety of both the client and the potential fetus.

Choice C reason: Continuing with surgery as scheduled without confirming the pregnancy status is not appropriate. Anesthesia and surgical procedures can pose risks to a pregnant client and the fetus. It is essential to verify the pregnancy status to make an informed decision about the safety and necessity of the surgery.

Choice D reason: Calculating gestation from the last menstrual cycle can provide an estimate of the pregnancy duration, but it does not confirm pregnancy. A bedside pregnancy test should be performed first to confirm whether the client is pregnant before considering gestational age. This information can then be used to further assess the situation and plan appropriate care.

A. Biliary duct obstruction. B. Surgical site infection. C. Hepatorenal failure. D. Acute pancreatitis.

Correct Answer is D

Explanation

Choice A reason: Biliary duct obstruction can cause symptoms similar to those described, such as abdominal pain and vomiting. However, the key indicators of acute pancreatitis are the elevated serum amylase and lipase levels, which are significantly higher than normal. These enzymes are typically elevated in cases of pancreatitis, making this the more accurate diagnosis.

Choice B reason: Surgical site infection could cause fever and pain, but it would not typically result in elevated serum amylase and lipase levels. These enzymes are specific to pancreatic inflammation and damage, which is characteristic of acute pancreatitis. Therefore, surgical site infection is less likely given the lab results.

Choice C reason: Hepatorenal failure involves liver and kidney dysfunction, which can present with various symptoms, including abdominal pain and vomiting. However, it does not typically cause a significant increase in serum amylase and lipase levels. These elevated levels are more indicative of pancreatic inflammation, pointing towards acute pancreatitis.

Choice D reason: Acute pancreatitis is characterized by upper abdominal pain radiating to the back, vomiting, fever, and significantly elevated serum amylase and lipase levels. These symptoms and lab results align with the diagnosis of acute pancreatitis, making it the correct choice.

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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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While completing a health assessment for a young adult female with acute appendicitis, the client informs the nurse that there is a chance that she may be pregnant. The operating team is preparing to take the client to surgery. Which intervention should the nurse implement immediately?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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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.