The nurse is caring for a client who reports a sudden, severe headache, and facial numbness.The nurse asks the client to smile and observes an uneven smile with a 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. After obtaining vital signs, the nurse should implement which intervention?

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

Maintain elevated positioning of the dependent joints on affected side.

Raise the head of the bed to 30 degrees keep head and neck in neutral alignment.

Determine when symptoms began and if improved or worsened since onset.

Answer and Explanation

The Correct Answer is D

A)   Incorrect- While monitoring urinary output is important for overall assessment, it is not the most critical intervention in this situation of suspected stroke. The client's neurological symptoms take precedence.
B)   Incorrect- Positioning might be relevant to preventing complications, but it is not the highest priority intervention in this situation. The focus should be on assessing the client's neurological status and determining appropriate intervention.
C)   Incorrect- Although head positioning is relevant for intracranial pressure management, it is not the immediate priority. The nurse should first assess the time of symptom onset and determine if the client is experiencing an acute stroke.
D)   Correct- The client's symptoms, including sudden severe headache, facial numbness, facial droop, and weakness on one side, are suggestive of a stroke. The nurse should prioritize assessing the time of symptom onset, as time is a crucial factor in determining the appropriate intervention. Rapid intervention can improve outcomes in stroke cases, especially when considering interventions like thrombolytic therapy. The other options are not as directly relevant to the immediate management of a suspected stroke.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A) Correct - Flaring of the nares is a sign of increased respiratory effort and can indicate acute respiratory distress.
B) Incorrect - While a resting respiratory rate of 35 breaths/min is elevated for a 4-month-old infant, it may not necessarily indicate acute distress, especially when considered along with other signs.
C) Incorrect - Bilateral bronchial breath sounds may indicate lung pathology, but they are not specific to acute respiratory distress.
D) Incorrect - Diaphragmatic respirations, where the abdomen moves more than the chest during breathing, are normal for infants. They do not necessarily indicate acute respiratory distress.

A. Liver enzymes. B. Complete blood count. C. Serum electrolytes. D. Platelet count.

Correct Answer is B

Explanation

A) Incorrect- Liver enzymes are important for assessing liver function, but they are not the primary concern when a client with chronic kidney disease is feeling increasingly tired. Epoetin alfa injections are used to stimulate red blood cell production, so the nurse should review a laboratory value related to anemia.
B) Correct- Epoetin alfa is a medication that stimulates the production of red blood cells and is often used to treat anemia associated with chronic kidney disease. A complete blood count (CBC) would provide information about red blood cell levels, hemoglobin, and hematocrit, which are essential for assessing the effectiveness of the treatment.
C) Incorrect- Serum electrolytes are important for assessing overall kidney function and electrolyte balance, but the primary concern here is the client's increasing fatigue. Reviewing a value related to anemia and red blood cell production would be more appropriate.
D) Incorrect- Platelet count is important for assessing blood clotting function, but it's not directly related to the client's increasing fatigue. Anemia-related laboratory values should be the focus.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 4-month-old infant is brought to the clinic by a parent with symptoms of a runny nose, a slight fever, and cough for the last two days Which finding should alert the nurse that the child is in acute respiratory distress?

Correct Answer is A

Explanation

A client with chronic kidney disease reports to the nurse of feeling increasingly tired. The client receives injections for epoetin alfa three times a week. Which laboratory value should the nurse review?

Correct Answer is B

Explanation

Prior to an invasive examination of a hospitalized client, a consent form should be obtained. Which action best describes the responsibility of the practical nurse (PN)?

The practical nurse (PN) prepares to remove a client's saline lock. Which supplies should the PN gather? (Select all that apply.)

At a prenatal visit, a primigravida client confides to the practical nurse (PN) that her partner is abusive. Which information should the PN provide?

The nurse enters the room of a client with Parkinson's disease who is taking carbidopa-levodopa. The client is rising slowly from the chair while the unlicensed assistive personnel (UAP) stands next to the chair. Which action should the nurse take?

Find patient data below. Exhibits here What actions should the nurse plan for the rest of the shift? Select all that apply.

While receiving report for a client with carcinoma in situ of the left breast, the practical nurse (PN) reviews a pending lab report and notices increased levels of Anti-Glycan Neu5Gc Antibodies (AGNA). Which changes should the PN anticipate to be included in the client's plan of care?

The practical nurse (PN) plans to screen only high risk children for scoliosis. Which group of children should the PN screen?