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 D

Explanation

Choice A reason: While developing new screening protocols is a positive step, it does not directly measure the effectiveness of the prevention program in terms of client outcomes or behavior change.

Choice B reason: Early diagnosis of at-risk clients is important, but it is a secondary measure of effectiveness that follows education and behavior change, which are primary prevention strategies.

Choice C reason: Prompt rehabilitation for clients with disease complications is a form of tertiary prevention and does not reflect the effectiveness of the primary prevention program.

Choice D reason: Improvement in client knowledge about specific risk factors as evidenced by test scores is a direct measure of the effectiveness of an educational prevention program. It indicates that clients have understood and potentially internalized the information necessary to prevent sexually transmitted diseases, which is the goal of primary prevention.

A. Assume care of the client and assign the PN to the care of a different client. B. Arrange for unlicensed assistive personnel to assist the PN during the procedure. C. Acknowledge that the PN has positioned the client safely and correctly. D. Demonstrate to the PN how to position the client more effectively for the procedure.

Correct Answer is D

Explanation

Choice A reason: Assuming care of the client and reassigning the PN does not address the immediate need to correct the client's position for the sigmoidoscopy.

Choice B reason: While assistance may be needed, it is more important to first ensure that the client is in the correct position for the procedure.

Choice C reason: Acknowledging the PN's action would be incorrect since the client has not been positioned safely and correctly for a sigmoidoscopy.

Choice D reason: Demonstrating the correct positioning ensures the procedure can be performed effectively and safely, which is the nurse's immediate responsibility.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse implements a primary prevention program for sexually transmitted diseases in a nurse-managed health center. Which outcome indicates that the program was effective?

Correct Answer is D

Explanation

A nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

Correct Answer is D

Explanation

A client who is confined to a wheelchair as a result of a motorcycle accident is unable to feel pain or pressure from the waist down. Which finding provides the nurse with the earliest indication that the client is developing a pressure ulcer?

One hour following cardiac catheterization via the left femoral site, a client reports feeling weak and dizzy. Assessment reveals that the client's dressing is dry and intact. Which action should the nurse take next?

A client receives a prescription for itraconazole. Which statement made by the client requires additional instruction by the nurse?

The nurse is caring for an older adult client with a history of osteoarthritis who is having difficulty walking due to increased right knee pain. To assess the quality of the client's knee pain, which approach should the nurse use?

What conditions are most likely to respond to treatment with antihistamines? Select all that apply.

A client arrives for an annual physical exam and reports having calf pain. The client's health history includes peripheral arterial disease. Which question should the nurse ask the client about expected findings related to chronic arterial symptoms?

On admission to the emergency department, a client who was diagnosed with bipolar disorder 3 years ago reports taking a handful of medications this morning and left a suicide note for the family. Which information is most important for the nurse to obtain?

An older adult client arrives at the clinic describing a new onset of urinary incontinence. Which intervention should the nurse implement?