Patient Profile:
- Age: 68 years
- Gender: Male
- Medical History: Hypertension, Type 2 Diabetes Mellitus
- Medications: Lisinopril, Metformin
- Allergies: None
Chief Complaint: The patient presents to the emergency department (ED) with sudden onset of right-sided weakness and difficulty speaking that began approximately 1 hour prior to arrival.
Choose three parameters the nurse should monitor to assess the patient's progress.
Respiratory status
Liver enzymes
Blood pressure
Neurological status
Potassium level
Correct Answer : A,C,D
Choice A reason: Respiratory status is crucial to monitor because patients with acute neurological deficits, such as those seen in strokes, are at risk of respiratory compromise. This can be due to weakened respiratory muscles or aspiration, which could lead to pneumonia or other respiratory complications.
Choice B reason: Monitoring liver enzymes is not directly related to the acute management of a stroke patient. Liver enzymes would be more relevant in cases where liver function or hepatic issues are suspected, but not for this specific scenario.
Choice C reason: Blood pressure monitoring is vital, as hypertension is a significant risk factor for stroke. Maintaining appropriate blood pressure is essential to prevent further neurological damage and complications. Acute changes in blood pressure can indicate worsening or improvement of the patient's condition.
Choice D reason: Neurological status should be continuously monitored to assess the progression of the patient's stroke symptoms. This includes checking for changes in level of consciousness, motor function, speech, and other neurological signs. Prompt detection of changes can guide immediate interventions.
Choice E reason: Potassium level monitoring is not a primary focus in the acute management of stroke. While electrolyte balance is important, it is not as critical as respiratory status, blood pressure, and neurological status in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Weight gain is not commonly associated with Parkinson's disease. In fact, patients with PD often experience weight loss due to increased energy expenditure from tremors and muscle rigidity, as well as difficulties with eating.
Choice B reason: Cardiovascular problems are not directly caused by Parkinson's disease. While PD patients may have cardiovascular issues, these are typically related to age or other comorbid conditions rather than PD itself.
Choice C reason: Swallowing challenges, or dysphagia, are a significant concern for patients with Parkinson's disease. The motor symptoms of PD, including muscle rigidity and bradykinesia, can affect the muscles involved in swallowing, leading to difficulty eating and an increased risk of aspiration and choking. Addressing swallowing challenges is crucial for maintaining nutrition and preventing respiratory complications.
Choice D reason: Obesity is not a typical issue for patients with Parkinson's disease. As mentioned earlier, weight loss is more common due to the disease's impact on motor function and the effort required for daily activities.
Correct Answer is ["B"]
Explanation
Choice A reason: Cleaning the stoma two times a week is not sufficient. Stoma care typically requires daily cleaning to prevent infection and ensure the area remains free from mucus buildup and irritation.
Choice B reason: Using a bedside humidifier is important for patients with a tracheostomy. The humidified air helps to keep the stoma and airway moist, preventing drying and crusting of secretions, which can obstruct the airway.
Choice C reason: Offering plenty of fluids to the patient helps to keep the mucus thin and easier to clear, which is crucial for maintaining a clear airway in patients with a tracheostomy.
Choice D reason: Keeping the stoma uncovered when the patient showers is incorrect. The stoma should be covered with a waterproof shield or dressing to prevent water from entering the airway, which can cause respiratory distress or infection.
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