The nurse is caring for a client who arrives at the emergency department with reports of experiencing dizziness and difficulty walking to the bathroom. The nurse observes right-sided weakness and sluggish enunciation of speech. After obtaining vital signs, the nurse should implement which intervention?

Initiate bilateral intermittent sequential pneumatic compression devices.

Place an indwelling urinary catheter and measure strict intake and output.

Notify the stroke team to assist with acute assessment and management.

Administer aspirin to prevent further clot formation and platelet clumping.

Answer and Explanation

The Correct Answer is C

Choice A reason: While pneumatic compression devices are used for DVT prevention, they are not the immediate intervention for suspected stroke.

Choice B reason: Placing an indwelling urinary catheter is not the first-line intervention for a patient with suspected stroke symptoms.

Choice C reason: Notifying the stroke team is the most appropriate action as the patient's symptoms suggest a possible stroke, requiring urgent evaluation and management.

Choice D reason: Aspirin may be used in the management of stroke, but only after a stroke has been confirmed and not as an immediate intervention.

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Correct Answer is A

Explanation

Choice A reason: Engaging in non-threatening conversations can help the client feel more comfortable and may encourage communication, which is crucial for clients who are withdrawn due to depression.

Choice B reason: Family visits can be supportive, but the client's withdrawal suggests a need for more direct intervention to encourage communication.

Choice C reason: Scheduling a conference with a social worker is important, but it is not the most immediate intervention for a withdrawn client.

Choice D reason: Group activities may be overwhelming for a client who is noncommunicative and may not be the most suitable initial approach.

A. Blood pressure 130/80 mm Hg. B. Serum creatinine 1.6 mg/dL (141.44 µmol/L). C. Dark yellow urine. D. Difficulty staying asleep.

Correct Answer is B

Explanation

Choice A reason: A blood pressure of 130/80 mm Hg is considered high normal and may not require immediate follow-up for a patient with a history of hypertension.

Choice B reason: A serum creatinine of 1.6 mg/dL is above the normal range for both males and females, indicating possible kidney dysfunction, which requires further follow-up.

Choice C reason: Dark yellow urine could be a sign of dehydration, which is common in diabetes, but it is not as concerning as an elevated serum creatinine level.

Choice D reason: Difficulty staying asleep could be related to various factors and may require follow-up, but it is not as urgent as abnormal laboratory values.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse notes that a client with depression has been more withdrawn and noncommunicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

After receiving a change of shift report for clients on a medical-surgical unit, which activity should the nurse delegate to the practical nurse (PN)?

A client who is one day postpartum reports to the nurse that her baby cannot latch onto the breast. The nurse observes that the client's nipples are inverted. Which action should the nurse implement?

The nurse is assisting the healthcare provider with a wound debridement at the bedside of a client who is mildly confused. The client is draped and a sterile field is created. Which nursing intervention should the nurse implement for client safety?

A nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. Which action should the nurse take?

The nurse is developing a plan of care for a client who reports chest pain on exertion and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?

Patient Data Exhibits Based on the results of the echocardiogram, the physician has decided to repair the ventricular septal defect via cardiac catheterization. What should the nurse’s focused assessment include before the cardiac catheterization? Select all that apply.

A client who is one day postpartum reports that her baby cannot latch onto the breast. The nurse observes that the client's nipples are inverted. Which action should the nurse implement?