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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Imbalanced nutrition due to anorexia and dysphagia is significant in esophageal cancer, as it risks weight loss and weakness. However, pain at 8/10 is an acute, distressing symptom requiring immediate relief to improve quality of life, making it the priority over nutritional deficits.
Choice B reason: Risk for aspiration from dysphagia is a concern in esophageal cancer, as tumor obstruction can cause swallowing issues. While serious, aspiration is a potential risk, whereas severe pain is an immediate, actual problem, making pain management the priority to alleviate current suffering.
Choice C reason: Anxiety and grieving are valid in esophageal cancer due to its prognosis, but a pain level of 8/10 is an urgent physiological need. Addressing pain first improves the client’s ability to cope with psychological distress, prioritizing physical comfort over emotional concerns.
Choice D reason: Chronic pain from tumor-related tissue destruction, rated 8/10, is the priority, as severe pain causes significant distress and impairs function. Effective pain management enhances comfort, facilitates other interventions, and addresses the client’s immediate suffering, making it the most urgent nursing problem.
Correct Answer is D
Explanation
Choice A reason: Chronic constipation and serum gastrin levels are not directly relevant to acute pancreatitis. Constipation may indicate gastrointestinal issues, but gastrin primarily relates to gastric acid secretion. These do not confirm pancreatitis or guide acute management, unlike amylase levels, which are diagnostic for pancreatic inflammation.
Choice B reason: Helicobacter pylori antibodies indicate gastric infection, unrelated to pancreatitis, which involves pancreatic inflammation. Urine output is a general vital sign but not specific to pancreatitis diagnosis. Amylase and symptom severity are more critical for confirming and managing acute pancreatitis, making this less valuable.
Choice C reason: Bowel sounds and abdominal pain degree provide general information but are nonspecific. Pain is expected in pancreatitis, and bowel sounds may vary. Serum amylase and nausea/vomiting severity are more diagnostic, directly reflecting pancreatic inflammation and its systemic effects, making them more critical to report.
Choice D reason: Serum amylase levels are a key diagnostic marker for acute pancreatitis, as pancreatic inflammation releases amylase into the blood. Severity of nausea and vomiting reflects disease impact and fluid loss, guiding treatment. These are the most valuable data for reporting, as they confirm diagnosis and inform management.
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