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 B
Explanation
Choice A reason: Upper GI bleeding is not a direct cause of right heart failure (cor pulmonale). While severe GI bleeding can lead to other complications such as anemia or shock, it does not typically result in cor pulmonale.
Choice B reason: Chronic obstructive pulmonary disease (COPD) is a primary cause of cor pulmonale. COPD leads to chronic hypoxia, which increases pressure in the pulmonary arteries (pulmonary hypertension). The right ventricle of the heart must work harder to pump blood through these high-pressure arteries, eventually leading to right heart failure.
Choice C reason: Liver failure can lead to various systemic complications such as fluid imbalance and electrolyte disturbances, but it is not a direct cause of right heart failure (cor pulmonale). Cor pulmonale is specifically related to pulmonary conditions that increase right ventricular workload.
Choice D reason: Renal failure, while serious and capable of causing cardiovascular complications due to fluid overload and hypertension, is not typically linked to the development of cor pulmonale. The primary cause of cor pulmonale is chronic lung disease like COPD, which directly affects the pulmonary vasculature.
Correct Answer is ["A","B"]
Explanation
Choice A reason: Warfarin should be held before surgery due to its anticoagulant properties. Continuing warfarin increases the risk of excessive bleeding during and after surgery. The patient's INR level is already elevated, indicating a higher risk of bleeding.
Choice B reason: Metformin should be held before surgery, especially for patients undergoing procedures that involve the use of contrast dye or anesthesia. Metformin can cause lactic acidosis in patients with renal impairment or when kidney function is affected by contrast agents or surgery.
Choice C reason: Lisinopril is an ACE inhibitor used to manage blood pressure. While some guidelines suggest holding ACE inhibitors before surgery due to the risk of intraoperative hypotension, this decision is often individualized based on the patient's condition and the type of surgery. It is not as universally indicated to be held as warfarin and metformin.
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