Exhibits
Complete the following sentence by using the lists of options.
The nurse should first address the client
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
The nurse should first address the client pain level followed by the client's ECG results
Rationale
Pain level: Addressing the client's pain level is crucial because it directly affects their comfort and can be indicative of ongoing myocardial ischemia or infarction. The client initially reported chest pain as 7/10, which is significant. Although it has decreased to 5/10 after nitroglycerin, ongoing assessment of pain is essential to ensure it does not worsen or change in nature.
ECG results: The 12-lead electrocardiogram (ECG) shows tachycardia with ST segment elevation and T wave changes. These findings indicate acute myocardial ischemia or infarction, which is a critical concern. The ECG results guide further diagnosis and treatment decisions, such as determining the need for immediate reperfusion therapy (like thrombolytics or angioplasty).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. This location is preferred because it provides rapid and higher peak plasma epinephrine levels compared to other sites, which is crucial during an anaphylactic emergency.
A While this can be a safe IM injection site in some adults, it's not the preferred location for epinephrine during anaphylaxis. The muscle mass in the ventrogluteal area might be less reliable for quick absorption of the medication in an emergency situation.
C. avoided due to its proximity to major nerves (sciatic nerve) and blood vessels, which can lead to complications such as nerve damage or accidental injection into a blood vessel.
D. The deltoid is generally not recommended because it has a smaller muscle mass compared to the ventrogluteal or vastus lateralis sites.
Correct Answer is A
Explanation
A. Nuchal rigidity refers to stiffness or resistance to neck movement, especially when the client's head is flexed forward. It is a classic sign of meningitis due to irritation and inflammation of the meninges (the membranes surrounding the brain and spinal cord). This assessment helps to detect meningeal irritation, a hallmark of meningitis.
B. This action tests the deep tendon reflex, specifically the knee jerk reflex (patellar reflex). It assesses the integrity of the spinal cord and peripheral nerves. While it is part of a neurological assessment, it is not specifically related to the assessment of meningitis unless there are concurrent neurological symptoms or signs.
C This maneuver tests for Babinski reflex, which is an abnormal response where the toes flare upward and the big toe dorsiflexes when the sole of the foot is stimulated. A positive Babinski reflex can indicate dysfunction of the corticospinal tract or brain injury but is not a specific finding in meningitis.
D. Tapping the facial nerve (cranial nerve VII) assesses for the presence of facial nerve irritation or damage. In the context of meningitis, signs such as facial twitching or asymmetry may indicate involvement of cranial nerves due to inflammation and pressure within the skull.
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