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 B

Explanation

Choice A reason: Delegating oral care to UAP is appropriate for routine hygiene in AIDS patients with candidiasis. Leaving oral care solely to the nurse is unnecessary unless complex treatments are required. A soft-bristled toothbrush ensures safe, effective cleaning, supporting UAP involvement in standard oral hygiene.

Choice B reason: A soft-bristled toothbrush is ideal for oral care in candidiasis, as it gently cleans without traumatizing painful ulcers. In AIDS, oral hygiene reduces fungal load and discomfort. This instruction ensures safe, effective care by UAP, aligning with standard hygiene practices for mucosal infections.

Choice C reason: Sterile gloves are unnecessary for routine oral care, as candidiasis is not highly contagious in this context. Standard precautions, including clean gloves, suffice for UAP performing hygiene. Requiring sterile gloves is excessive, complicating care without added benefit compared to using a soft toothbrush.

Choice D reason: Mouthwash may irritate candidiasis ulcers, especially if alcohol-based, and is not the priority. Brushing with a soft-bristled toothbrush effectively cleans the mouth without causing trauma. Mouthwash is secondary and requires nurse oversight to ensure compatibility with the client’s condition, unlike brushing.

A. Limit potassium-rich foods B. Increase protein intake C. Restrict carbohydrate consumption D. Encourage high-sodium foods

Correct Answer is A

Explanation

Choice A reason: Limiting potassium-rich foods is critical in chronic kidney disease, as impaired renal excretion causes hyperkalemia, risking cardiac arrhythmias. Foods like bananas and oranges are restricted to maintain safe potassium levels, making this the priority dietary teaching to prevent life-threatening complications.

Choice B reason: Increasing protein intake is inappropriate, as chronic kidney disease requires protein restriction to reduce uremic toxins and kidney workload. Potassium restriction is prioritized, as hyperkalemia poses an immediate cardiac risk, making it the essential dietary focus over protein adjustments.

Choice C reason: Restricting carbohydrates is not standard in chronic kidney disease unless diabetes is present. Potassium restriction is critical, as elevated potassium levels from impaired renal clearance cause arrhythmias, making it the priority dietary intervention to ensure cardiac safety.

Choice D reason: Encouraging high-sodium foods is incorrect, as sodium restriction prevents fluid retention and hypertension in chronic kidney disease. Potassium restriction is the priority, as hyperkalemia directly threatens cardiac function, making it the essential dietary focus over sodium concerns.

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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

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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