The nurse is caring for a client who reports a sudden, severe facial numbness. The nurse observes an uneven smile with facial droop to the right side and a hand grasp strength that is weaker on the right than the left.

The client denies a recent history of headaches or trauma.

Which intervention should the nurse perform immediately?

Maintain elevated positioning of the dependent joints on the affected side.

Verify prescribed laboratory tests include prothrombin time and platelet count.

Start two large-bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.

Administer aspirin to prevent further clot formation and platelet clumping.

Answer and Explanation

The Correct Answer is C

Choice A rationale
While maintaining elevated positioning of the dependent joints on the affected side can be helpful in certain conditions such as edema or injury, it is not the immediate intervention needed for a client presenting with sudden, severe facial numbness, uneven smile with facial droop to the right side, and a hand grasp strength that is weaker on the right than the left.
Choice B rationale
Verifying prescribed laboratory tests including prothrombin time and platelet count is important in assessing the client’s coagulation status. However, it is not the immediate intervention needed in this situation.
Choice C rationale
The client’s symptoms are suggestive of a stroke. In such cases, immediate medical intervention is crucial. Starting two large-bore IV catheters and reviewing inclusion criteria for IV fibrinolytic therapy is an appropriate immediate intervention.
Choice D rationale
Administering aspirin can be beneficial in preventing further clot formation and platelet clumping in clients at risk of a stroke. However, it is not the immediate intervention needed in this situation.

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Correct Answer is D

Explanation

Choice A rationale
Adjusting food intake to three full meals per day with no snacks is not necessarily recommended for GERD patients. Smaller, more frequent meals can help prevent the stomach from becoming too full and causing reflux.
Choice B rationale
Avoiding participation in any aerobic exercise programs is not a general recommendation for GERD patients. While some exercises may worsen GERD symptoms, many forms of aerobic exercise can be performed without triggering symptoms.
Choice C rationale
Sleeping without pillows at night to maintain neck alignment is not typically recommended for GERD patients. Elevating the head of the bed can actually help prevent acid reflux during sleep.
Choice D rationale
Wearing loose, comfortable clothing can help minimize GERD symptoms. Tight clothing can put pressure on the abdomen and the lower esophageal sphincter, potentially causing reflux.

A. White blood cell count. B. Platelet count. C. Red blood cell count. D. Hemoglobin levels.

Correct Answer is B

Explanation

Choice A rationale
While a white blood cell count can indicate an infection or inflammation in the body, it’s not the most relevant laboratory result to review when a client presents with petechiae and ecchymosis. These symptoms are more commonly associated with platelet disorders or coagulation issues.
Choice B rationale
A platelet count is the most relevant laboratory result to review for a client with petechiae and ecchymosis. These symptoms are often caused by low platelet counts, which can lead to bleeding and bruising. Therefore, reviewing the platelet count can provide valuable information about the client’s condition.
Choice C rationale
A red blood cell count can provide information about the client’s overall health and can indicate conditions like anemia. However, it’s not directly related to the presence of petechiae and ecchymosis.
Choice D rationale
Hemoglobin levels can indicate conditions like anemia, but they’re not directly related to the presence of petechiae and ecchymosis. These symptoms are more commonly associated with platelet disorders or coagulation issues.

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Naxlex Comprehensive Predictor Exams

What information should the nurse include in the teaching plan for a patient diagnosed with gastroesophageal reflux disease (GERD)?

Correct Answer is D

Explanation

The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?

Correct Answer is B

Explanation

While providing care for a patient with Guillain-Barre syndrome, the nurse conducts a neurological assessment every four hours. Which finding from the assessment requires immediate intervention by the nurse?

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The nurse is providing discharge teaching to an older patient hospitalized for treatment of venous leg ulcers. What instructions should the nurse include in the teaching plan? (Select all that apply.)

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