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.

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Correct Answer is B

Explanation

A) Incorrect- While a second IV site might be considered if the first one is causing significant discomfort, it's not the initial intervention. The nurse should first address the immediate concern of pain.
B) Correct- Pain at the IV site during infusion might indicate infiltration or irritation. Stopping the infusion is the most immediate intervention to prevent further discomfort and potential complications like tissue damage.
C) Incorrect- While assessing for blood return is important to ensure proper IV placement, it's not the initial intervention for managing pain caused by the infusion.
D) Incorrect- Discontinuing the IV might be considered if the pain is severe and unmanageable, but the nurse should initially try to address the discomfort without removing the IV.

A. "Hyperglycemia often results in weight loss." B. "Hyperglycemia causes an increased sensation of being hungry." C. "Hyperglycemia causes cool and clammy skin." D. "Hyperglycemia often presents as increased thirst and urination." E. "Hyperglycemia causes a headache and flushed, dry skin."

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

Explanation

A) Incorrect - Hyperglycemia typically does not lead to weight loss. In fact, it can result in weight gain due to the body's inability to properly use glucose for energy.

B) Correct - Hyperglycemia can lead to an increased sensation of hunger as the body's cells are not effectively receiving the glucose they need for energy, causing the person to feel hungry.
C) Incorrect - Cool and clammy skin are not typical symptoms of hyperglycemia. Hyperglycemia can lead to dry skin, but it does not cause cool and clammy skin.
D) Correct - Hyperglycemia often leads to increased thirst and urination. Excess glucose in the blood can cause the kidneys to work harder to filter and eliminate the glucose, leading to increased fluid intake and subsequently increased urination.
E) Hyperglycemia can cause dehydration, leading to dry, flushed skin and sometimes headaches due to electrolyte imbalances and reduced blood flow to the brain.

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Naxlex Comprehensive Predictor Exams

A client who was admitted yesterday with severe dehydration is reporting pain where a 24 gauge intravenous (IV) catheter with normal saline is infusing at a rate of 150 mL/hour. Which intervention should the nurse implement first?

Correct Answer is B

Explanation

Patient Data Exhibits Which are the nurse's best responses? Select all that apply.

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

Explanation

The practical nurse (PN) observes two unlicensed assistive personnel (UAP) turning an older client who had a hip arthroplasty with prosthesis placement four hours ago. Which observation by the PN indicates that the UAPs need additional information about the turning procedure?

The nurse identifies an electrolyte imbalance, elevated blood pressure, and exhibited changes in mental status for a client with chronic kidney disease. Which is the most important action for the nurse to take?

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?

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

Before leaving the room of a confused client, the nurse notes that a half-bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room?

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?

When the practical nurse (PN) attempts to assist an 18-year-old client with a mild mental disability to ambulate on the first postoperative day after an appendectomy, she becomes angry and says, "PN, 'Get out of here! I'll get up when I'm ready!" Which response is best for the PN to make?