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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: Ascites, fluid accumulation in the peritoneal cavity, is a common complication of liver cirrhosis due to portal hypertension and hypoalbuminemia. It increases infection risk and discomfort, making it the priority to monitor, as early detection guides diuretic therapy and paracentesis.

Choice B reason: Peripheral neuropathy is not a primary cirrhosis complication, though it may occur in alcoholic liver disease. Ascites is more common, resulting from portal hypertension, making it the priority to monitor, as it directly reflects liver dysfunction and requires urgent management.

Choice C reason: Pulmonary edema is associated with heart failure, not cirrhosis. Ascites is a hallmark of cirrhosis, caused by portal hypertension and low albumin, making it the priority complication to monitor, as it indicates worsening liver function and requires immediate intervention.

Choice D reason: Kidney stones are unrelated to cirrhosis, which primarily causes ascites due to portal hypertension. Monitoring ascites is critical, as it reflects liver decompensation, increasing risks like spontaneous bacterial peritonitis, making it the priority over unrelated renal conditions.

A. Apply warm compresses to affected joints B. Restrict all physical activity C. Administer high-dose corticosteroids D. Encourage high-sodium diet

Correct Answer is A

Explanation

Choice A reason: Warm compresses reduce morning stiffness in rheumatoid arthritis by increasing blood flow and relaxing muscles around inflamed joints. This alleviates synovial inflammation, improving mobility and comfort, making it a key nonpharmacologic intervention to manage early daily symptoms effectively.

Choice B reason: Restricting physical activity worsens stiffness and joint deformity in rheumatoid arthritis. Warm compresses are prioritized, as they directly reduce synovial inflammation and improve mobility, enabling gentle exercise, making complete activity restriction counterproductive to joint health and function.

Choice C reason: High-dose corticosteroids are reserved for severe rheumatoid arthritis flares, not routine morning stiffness. Warm compresses are safer, reducing stiffness through localized heat, improving joint function without systemic side effects, making them the priority intervention for daily symptom management.

Choice D reason: A high-sodium diet increases fluid retention, potentially worsening joint inflammation in rheumatoid arthritis. Warm compresses directly alleviate morning stiffness by enhancing circulation, making them the priority, as dietary sodium does not address acute joint symptoms effectively.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 liver cirrhosis. Which complication should the nurse monitor for?

Correct Answer is A

Explanation

The nurse is caring for a client with a history of rheumatoid arthritis who reports morning stiffness. Which intervention should the nurse include?

Correct Answer is A

Explanation

The nurse is caring for a client with a history of deep vein thrombosis. Which intervention should the nurse include in the care plan?

The nurse is caring for a client with a history of breast cancer who is receiving chemotherapy. Which side effect should the nurse monitor for?

The nurse is caring for a client with a new diagnosis of asthma. Which teaching point should the nurse emphasize for proper inhaler use?

The nurse is admitting a client with possible tuberculosis (TB). The client is placed in a private room with airborne precautions pending diagnostic test results. Which diagnostic test should the nurse review to confirm the diagnosis of TB?

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

The nurse is caring for a client with a new diagnosis of hyperthyroidism. Which intervention should the nurse prioritize?

A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently burn and sometimes bleed. Which prescription should the nurse teach the client to use for the skin condition?

The nurse is caring for a client with a history of gout. Which dietary recommendation should the nurse emphasize?