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: Serum creatinine assesses kidney function, not cardiac injury. While relevant for overall health, it does not confirm myocardial infarction. Troponin is specific to cardiac muscle damage, making it the priority test to diagnose acute coronary events in the emergency setting.

Choice B reason: Troponin levels are the gold standard for diagnosing myocardial infarction, as they rise within hours of cardiac muscle injury due to ischemia. High specificity for heart tissue makes troponin critical for confirming acute coronary syndrome, guiding urgent treatment in the emergency department.

Choice C reason: Complete blood count evaluates anemia or infection but is nonspecific for myocardial infarction. While useful for overall assessment, it does not detect cardiac injury. Troponin directly indicates heart muscle damage, making it the priority test for confirming the diagnosis.

Choice D reason: Blood glucose may be elevated in stress or diabetes but is not diagnostic for myocardial infarction. Cardiac-specific markers like troponin are essential for confirming heart injury, as glucose levels lack specificity for acute coronary events, making them secondary.

A. Imbalanced nutrition less than body requirements B. Risk for aspiration related to difficulty swallowing C. Anxiety and grieving related to progression of disease D. Chronic pain related to tissue destruction by tumor

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.

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

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Naxlex Comprehensive Predictor Exams

A client is admitted to the emergency department with a suspected myocardial infarction. Which laboratory test should the nurse prioritize to confirm the diagnosis?

Correct Answer is B

Explanation

The nurse is caring for a client who has been admitted with a diagnosis of esophageal cancer. The client reports a pain level of 8 on a 0 to 10 scale, dysphagia, anorexia, anxiety, and a hoarse voice. Which nursing problem is the priority for this client?

Correct Answer is D

Explanation

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