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 B

Explanation

Choice A rationale
While the renin-angiotensin response can be affected in cirrhosis, it is not the primary mechanism contributing to edema and ascites. In cirrhosis, there can be a decrease in renal blood flow which can lead to activation of the renin-angiotensin system, but this is not the main cause of fluid accumulation.
Choice B rationale
Hypoalbuminemia, or low levels of albumin in the blood, is a common occurrence in cirrhosis. Albumin is a protein that helps maintain oncotic pressure, which keeps fluid in the blood vessels. When albumin levels are low, fluid can leak out of the blood vessels and accumulate in the abdomen (ascites) and in the tissues, causing edema.
Choice C rationale
Hyperaldosteronism can occur in cirrhosis and can contribute to fluid retention. However, it is not the primary mechanism leading to edema and ascites. Aldosterone promotes sodium and water reabsorption in the kidneys, which can contribute to fluid retention, but this is usually a secondary response to other changes in the body.
Choice D rationale
Decreased portacaval pressure with greater collateral circulation is not the primary mechanism contributing to edema and ascites in cirrhosis. While portal hypertension is a common complication of cirrhosis, it is not directly responsible for the development of edema and ascites.

A. The patient should eat a diet high in protein and vitamins A and C. B. The patient should keep their legs elevated when sitting or lying down. C. The patient should maintain as much bed rest as possible. D. The patient should inspect their ankles daily for areas of darkening skin. E. The patient should apply intermittent cold compresses four times daily.

Correct Answer is ["A","B","D"]

Explanation

Choice A rationale
A diet high in protein and vitamins A and C can help promote wound healing. Protein is essential for tissue repair, and vitamins A and C play crucial roles in wound healing and immune function.
Choice B rationale
Keeping legs elevated when sitting or lying down can help reduce swelling and improve blood circulation, which is beneficial for healing venous leg ulcers.
Choice C rationale
Maintaining as much bed rest as possible is not typically recommended for patients with venous leg ulcers. Physical activity and movement can help improve blood circulation, which is beneficial for healing venous leg ulcers.
Choice D rationale
Inspecting ankles daily for areas of darkening skin can help detect early signs of worsening venous leg ulcers. Early detection and treatment can prevent complications and promote healing.
Choice E rationale
Applying intermittent cold compresses four times daily is not typically recommended for venous leg ulcers. Cold compresses can constrict blood vessels and reduce blood flow to the area, which may hinder the healing process.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis?

Correct Answer is B

Explanation

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.)

Correct Answer is ["A","B","D"]

Explanation

A client with right hydronephrosis and a history of renal calculi is preparing for discharge following a retrograde pyelogram. Which instruction should the nurse include in the client’s discharge instructions?

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?

The parent of an adolescent tells the clinic nurse, “My child has athlete’s foot. I have been applying triple antibiotic ointment for two days, but there has been no improvement.”. Which instruction should the nurse provide?

An hour after administering 60 mg of furosemide intravenously (IV), which assessments should the nurse perform to determine the patient’s response to treatment? (Select all that apply.)

While assessing a patient with degenerative joint disease, the nurse notices Heberden’s nodes, and large prominences on the patient’s fingers that are reddened and painful. What should the nurse do?

The nurse is caring for a patient with chronic pancreatitis who reports persistent gnawing abdominal pain. What assessment data is most important for the nurse to obtain to help manage the patient’s pain?