The nurse is caring for a client with a suspected stroke. Which intervention should the nurse prioritize?

Administer aspirin as prescribed

Obtain a head CT scan

Monitor blood glucose levels

Elevate the head of the bed

Answer and Explanation

The Correct Answer is B

Choice A reason: Administering aspirin is appropriate for ischemic stroke but premature without confirming stroke type. Hemorrhagic stroke contraindicates aspirin. A head CT scan distinguishes ischemic from hemorrhagic stroke, guiding treatment, making it the priority to ensure safe intervention.

Choice B reason: Obtaining a head CT scan is the priority, as it differentiates ischemic from hemorrhagic stroke, critical for guiding treatment like thrombolytics or anticoagulation. Rapid imaging within the therapeutic window ensures timely intervention, minimizing brain damage, making it the essential first step.

Choice C reason: Monitoring blood glucose is important, as hyperglycemia worsens stroke outcomes, but it is secondary to confirming stroke type. A head CT scan provides diagnostic clarity, guiding urgent therapy, making imaging the priority over metabolic assessments in suspected stroke.

Choice D reason: Elevating the head of the bed reduces intracranial pressure but is not the first step. A head CT scan confirms stroke type, ensuring appropriate interventions like thrombolytics for ischemic stroke, making imaging critical to guide management and prevent further brain injury.

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Correct Answer is C

Explanation

Choice A reason: Using a soft foam collar may reduce skin irritation but risks dislodging the tracheostomy tube if not secured properly. Leaving old ties in place until new ones are secure ensures tube stability, preventing accidental decannulation, which is critical in early tracheostomy care.

Choice B reason: Knots close to the tracheostomy tube increase pressure on the skin, risking irritation or necrosis. This is incorrect, as ties should allow slight movement. Maintaining old ties until new ones are secure prevents tube displacement, prioritizing airway safety during the procedure.

Choice C reason: Leaving old ties in place until new ones are secure prevents tracheostomy tube dislodgement, a life-threatening risk. This ensures continuous airway patency during tie changes, especially in fresh tracheostomies, making it the safest and most critical action to maintain tube stability.

Choice D reason: Placing knots laterally reduces irritation but does not address the risk of tube dislodgement during tie changes. Keeping old ties in place until new ones are secure is the priority, as it ensures the tube remains stable, preventing airway compromise.

A. Topical corticosteroids B. Topical analgesics C. Topical antibiotics D. Colloidal oatmeal-based lotion

Correct Answer is A

Explanation

Choice A reason: Topical corticosteroids reduce inflammation, scaling, and itching in psoriasis by inhibiting pro-inflammatory cytokines and immune responses in affected skin. They are first-line for plaque psoriasis with silvery scales, effectively managing burning and promoting healing of inflamed, bleeding areas on elbows and palms.

Choice B reason: Topical analgesics relieve pain but do not address psoriasis’s underlying inflammation or scaling. Psoriatic plaques are primarily inflammatory, not neuropathic. Analgesics may reduce burning temporarily but lack the anti-inflammatory action of corticosteroids, making them ineffective for managing chronic psoriatic lesions.

Choice C reason: Topical antibiotics treat bacterial infections, not psoriasis, which is an autoimmune inflammatory condition. Bleeding in psoriasis results from skin fragility, not infection. Antibiotics are unnecessary unless secondary infection is confirmed, making them inappropriate compared to corticosteroids, which target the disease’s inflammatory pathology.

Choice D reason: Colloidal oatmeal-based lotion soothes irritated skin and reduces itching but lacks anti-inflammatory properties to treat psoriasis’s scaling and inflammation. It may provide symptomatic relief but is inadequate for managing chronic plaques, unlike corticosteroids, which directly address the autoimmune-driven inflammation and scaling.

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The nurse is caring for a client with a suspected stroke. Which intervention should the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is securing a tracheostomy tube for a client post-procedure. Which action should the nurse take to ensure proper tracheostomy care?

Correct Answer is C

Explanation

A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently burn and sometimes bleed. Which prescription should the nurse teach the client to use for the skin condition?

Correct Answer is A

Explanation

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