The nurse receives information about the assigned patients during shift report.
Which patient would the nurse assess first?

A patient who reports dizziness with a blood pressure (BP) of 150/92 mm Hg.

A patient who reports a severe headache and has begun vomiting.

A patient with a hip fracture who reports a pain level of 2 on a 1-to-10 scale.

A patient who received an angiotensin-converting enzyme (ACE) inhibitor 30 minutes previously and reports fatigue.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Dizziness with a blood pressure of 150/92 mm Hg indicates hypertension, but it is not an immediate life-threatening condition requiring urgent assessment compared to a severe headache and vomiting.

Choice B rationale:

A severe headache and vomiting could be indicative of a serious neurological condition such as a stroke, intracranial bleeding, or increased intracranial pressure. This patient needs urgent assessment and intervention to prevent potential complications.

Choice C rationale:

A hip fracture with a pain level of 2 on a 1-to-10 scale suggests pain but is not immediately life-threatening compared to symptoms like severe headache and vomiting.

Choice D rationale:

Fatigue after receiving an ACE inhibitor is a common side effect and, while important to monitor, does not pose an immediate threat compared to the symptoms of severe headache and vomiting.

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Correct Answer is D

Explanation

Choice A rationale:

Thrombus formation is a later stage event in coronary artery disease (CAD) and occurs after the development of fatty streaks. Thrombus formation usually happens due to the rupture of atherosclerotic plaques, leading to platelet aggregation and clot formation.

Choice B rationale:

Formation of fibrous plaque in the endothelium is a progression that occurs after the initial development of fatty streaks. Fibrous plaques are formed as a response to the inflammation caused by fatty deposits. They are more stable than fatty streaks but can still lead to narrowing of the arteries.

Choice C rationale:

Reduction of blood flow through the coronary arteries is a consequence of atherosclerosis, which occurs after the initial development of fatty streaks. As the fatty deposits accumulate, they narrow the arteries, leading to reduced blood flow. However, this is not the initial change that makes patients susceptible to CAD.

Choice D rationale:

Development of fatty streaks in the smooth muscles of the endothelium is the initial change that occurs in the development of atherosclerosis, making patients susceptible to coronary artery disease. Fatty streaks are composed of lipid-laden macrophages and smooth muscle cells. Over time, these fatty streaks can progress into fibrous plaques and eventually lead to complications such as thrombus formation and reduced blood flow.

A. Adequate platelet production. B. Deficiency in intrinsic clotting system factor. C. Impairment of the thrombin fibrinogen reaction. D. Variable factor VIII deficiencies and platelet dysfunction.

Correct Answer is D

Explanation

Choice A rationale:

Adequate platelet production does not explain the prolonged bleeding times in von Willebrand disease. These patients often have normal platelet counts, but their platelets do not function properly due to the absence or dysfunction of von Willebrand factor.

Choice B rationale:

Deficiency in intrinsic clotting system factor is not the primary cause of prolonged bleeding times in von Willebrand disease. The deficiency or dysfunction of von Willebrand factor, a protein that helps platelets adhere to the blood vessel walls and clot properly, is the key issue in this disorder.

Choice C rationale:

Impairment of the thrombin fibrinogen reaction does not directly relate to von Willebrand disease. This disorder primarily involves platelet dysfunction and variable factor VIII deficiencies, leading to prolonged bleeding times.

Choice D rationale:

Variable factor VIII deficiencies and platelet dysfunction are characteristic of von Willebrand disease. Factor VIII helps with blood clotting, and its deficiency, along with impaired platelet function, contributes to the prolonged bleeding times in patients with von Willebrand disease.

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The nurse receives information about the assigned patients during shift report.Which patient would the nurse assess first?

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Naxlex Comprehensive Predictor Exams

Which change occurs first, making patients susceptible to coronary artery disease?

Correct Answer is D

Explanation

The nurse recognizes that patients with von Willebrand disease are at risk for prolonged bleeding times for which reason?

Correct Answer is D

Explanation

A healthy 70-year-old patient has low hemoglobin levels and no signs of gastrointestinal bleeding.The nurse recognizes which item is an effect of aging that could be the reason for the low hemoglobin level?

The nurse suspects that which condition associated with chronic heart failure is the cause of a patient's inability to sleep well due to frequent urination?

A patient reports episodic chest pain lasting a few minutes that is provoked by exertion and relieved within 10 minutes upon resting.Which cause of the patient's symptoms would the nurse suspect?

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Which arterial blood gas (ABG) data corresponds with a patient's clinical manifestations of respiratory alkalosis?

Which finding would the nurse expect to see in a patient with a hemoglobin level of 8 g/dL? Select all that apply.One, some, or all responses may be correct.

The nurse receives information about the assigned patients during shift report.
Which patient would the nurse assess first?