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 A

Explanation

Choice A reason: Assisting with mobility and safety is critical in multiple sclerosis, as muscle weakness and spasticity increase fall risk. Physical therapy and assistive devices enhance safety, reducing injury risk, making it the priority intervention to maintain independence and prevent complications like fractures.

Choice B reason: A high-sodium diet is inappropriate, as it may exacerbate fluid retention, unrelated to multiple sclerosis. Mobility assistance is the priority, as falls are a significant risk due to neurological deficits, making dietary sodium irrelevant to primary symptom management.

Choice C reason: Restricting physical therapy worsens mobility and spasticity in multiple sclerosis. Assisting with mobility and safety is critical, as it prevents falls and maintains function, making therapy restriction counterproductive, as exercise supports neurological health and independence.

Choice D reason: Promoting bed rest increases muscle atrophy and spasticity in multiple sclerosis. Mobility and safety measures are essential, as they reduce fall risk and maintain function, making bed rest detrimental to managing neurological symptoms and overall patient well-being.

A. Promote effective swallowing B. Prevent esophageal reflux C. Maintain intact oral mucosa D. Increase intestinal peristalsis

Correct Answer is B

Explanation

Choice A reason: Promoting effective swallowing is relevant for dysphagia but not the primary goal for sliding hiatal hernia, where the stomach protrudes into the thorax, causing reflux. Preventing acid reflux into the esophagus is critical to reduce irritation and complications like esophagitis, making swallowing secondary.

Choice B reason: Preventing esophageal reflux is the primary goal for sliding hiatal hernia, as the stomach’s protrusion through the diaphragm allows gastric acid to reflux, causing heartburn and esophageal damage. Nursing actions like elevating the head of the bed and avoiding trigger foods minimize reflux, protecting the esophagus.

Choice C reason: Maintaining intact oral mucosa is unrelated to hiatal hernia, which affects the gastroesophageal junction. Reflux causes esophageal, not oral, irritation. The focus is on preventing acid reflux to protect the esophagus, making oral mucosa maintenance irrelevant to the condition’s pathophysiology.

Choice D reason: Increasing intestinal peristalsis is not a goal for hiatal hernia, which involves gastroesophageal reflux, not intestinal motility. Enhanced peristalsis may worsen reflux by increasing intra-abdominal pressure. Preventing reflux is prioritized to manage symptoms and prevent esophageal complications.

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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 caring for a client with a history of multiple sclerosis. Which intervention should the nurse prioritize?

Correct Answer is A

Explanation

The nurse is planning care for a client with a direct (sliding) hiatal hernia. Nursing actions should be planned to meet which goal?

Correct Answer is B

Explanation

The nurse is caring for a client with a history of chronic obstructive pulmonary disease who is receiving oxygen therapy. Which assessment should the nurse prioritize?

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