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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
This statement is incorrect. Mexican Americans do not have higher rates of good blood pressure control compared to other populations.
Choice B rationale:
This statement is incorrect. Mexican Americans are not more likely to receive treatment for hypertension compared to other populations.
Choice C rationale:
This statement is incorrect. While hypertension is prevalent among Mexican Americans, stating they have the highest prevalence of hypertension in the world is inaccurate. The prevalence of hypertension is influenced by various factors and can vary across different regions globally.
Correct Answer is D
Explanation
Choice A rationale:
Triple-drug therapy is not the standard treatment for pernicious anemia after a gastrectomy. Pernicious anemia is primarily caused by vitamin B12 deficiency due to the absence of intrinsic factor, which is essential for vitamin B12 absorption.
Choice B rationale:
IV therapy is a broad term and does not specify the treatment for pernicious anemia. In the context of pernicious anemia, cobalamin replacement therapy administered via intramuscular injections is the preferred treatment.
Choice C rationale:
Quadruple-drug therapy is not a recognized treatment for pernicious anemia. The primary treatment for pernicious anemia involves cobalamin replacement therapy to address the vitamin B12 deficiency.
Choice D rationale:
Cobalamin replacement therapy is the appropriate treatment for pernicious anemia after a gastrectomy. Since the patient lacks intrinsic factor, which is necessary for vitamin B12 absorption, cobalamin replacement therapy bypasses the need for intrinsic factor and provides the necessary vitamin B12 directly.
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