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 A
Explanation
Choice A reason: Neutropenia, a low neutrophil count, is a common chemotherapy side effect due to bone marrow suppression, increasing infection risk. Monitoring neutrophil counts is critical, as infections in breast cancer patients can be life-threatening, making it the priority side effect to assess.
Choice B reason: Hypertension is not a typical chemotherapy side effect, though some agents cause cardiovascular effects. Neutropenia is more common, compromising immunity, making it the priority to monitor, as infections pose an immediate threat in breast cancer patients on chemotherapy.
Choice C reason: Hyperkalemia is rare with chemotherapy, except in tumor lysis syndrome. Neutropenia is a frequent side effect, increasing infection risk due to marrow suppression, making it the priority to monitor, as it directly impacts patient safety during breast cancer treatment.
Choice D reason: Weight gain is not a primary chemotherapy side effect; weight loss is more common due to nausea. Neutropenia is critical to monitor, as low neutrophils increase infection risk, requiring urgent intervention in breast cancer patients undergoing chemotherapy.
Correct Answer is A
Explanation
Choice A reason: Increasing iron-rich foods (e.g., red meat, spinach) corrects anemia by boosting hemoglobin synthesis, as iron is essential for red blood cell production. This addresses the underlying deficiency, improving oxygen transport, making it the priority dietary recommendation for anemia management.
Choice B reason: Limiting vitamin C is incorrect, as it enhances iron absorption, aiding anemia correction. Iron-rich foods are the priority, as they directly supply the deficient nutrient, improving hemoglobin levels, making vitamin C restriction counterproductive to effective anemia treatment.
Choice C reason: Restricting green leafy vegetables, which are iron-rich, worsens anemia. These foods (e.g., spinach) provide dietary iron, essential for hemoglobin synthesis. Increasing iron intake is the priority, as it corrects the deficiency, making vegetable restriction inappropriate for anemia.
Choice D reason: Avoiding whole grains is irrelevant, as they provide nutrients supporting overall health. Iron-rich foods directly address anemia by supplying iron for red blood cell production, making them the priority dietary recommendation over grain restrictions, which do not impact anemia correction.
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