The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding?

Jugular vein distention.

Carotid bruit.

Nuchal rigidity.

Palpable cervical lymph node.

Answer and Explanation

The Correct Answer is B

A. Jugular vein distention:
Jugular vein distention is not typically associated with an increased risk of a stroke. It may be indicative of issues related to cardiac or fluid volume status.

B. Carotid bruit:
This is the correct answer. A carotid bruit, an abnormal sound caused by turbulent blood flow through the carotid artery, may indicate the presence of atherosclerosis and increased risk of stroke. It suggests a narrowing or blockage in the carotid artery, which can potentially lead to emboli and subsequent stroke.

C. Nuchal rigidity:
Nuchal rigidity, stiffness of the neck, is associated with conditions such as meningitis but is not a direct risk factor for a stroke.

D. Palpable cervical lymph node:
Palpable cervical lymph nodes may be indicative of infection or inflammation in the head and neck region but are not directly associated with an increased risk of a stroke.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Instruct the client to drink plenty of fluids during the treatment.
This option focuses on hydration, which is generally important during chemotherapy to flush out toxins and maintain overall health. However, it does not specifically address the risk of vesicant extravasation.

B. Keep the head of the bed elevated until the treatment is completed.
Keeping the head of the bed elevated is a measure that may be taken for certain conditions or treatments, but it is not directly related to preventing vesicant extravasation.

C. Monitor the client's intravenous site hourly during the treatment.
This is the correct choice. Monitoring the intravenous site for signs of extravasation, such as swelling, redness, or pain, is crucial when administering vesicant chemotherapy drugs. Early detection allows for prompt intervention to minimize potential tissue damage.

D. Administer an antiemetic before starting the chemotherapy.
Administering an antiemetic (a medication to prevent or alleviate nausea and vomiting) is important for managing side effects of chemotherapy, but it does not specifically address the prevention of vesicant extravasation.

A. Remind the client to practice pelvic floor (Kegel) exercises regularly. B. Provide a bedside commode for immediate use in the client's room C. Explain the need to limit intake of oral fluids to reduce client discomfort. D. Teach the client techniques for performing intermittent catheterization.

Correct Answer is D

Explanation

A. Remind the client to practice pelvic floor (Kegel) exercises regularly.
Pelvic floor exercises, such as Kegel exercises, are typically recommended for conditions involving weakened pelvic floor muscles. However, in the context of urinary retention related to sensorimotor deficits in multiple sclerosis, the issue is more neurological in nature. Therefore, pelvic floor exercises may not address the underlying problem effectively.

B. Provide a bedside commode for immediate use in the client's room.
While a bedside commode may be beneficial for individuals with mobility issues, it doesn't directly address the problem of urinary retention. It focuses on providing a convenient means for the client to void when needed, but it doesn't address the inability to empty the bladder spontaneously.

C. Explain the need to limit intake of oral fluids to reduce client discomfort.
Limiting oral fluids is not an appropriate intervention for urinary retention. In fact, it could lead to dehydration, which is not a recommended approach. The focus should be on addressing the difficulty in voiding through appropriate techniques.

D. Teach the client techniques for performing intermittent catheterization.
This is the correct choice. Intermittent catheterization is a direct and effective method to manage urinary retention in clients with sensorimotor deficits. Teaching the client how to perform intermittent catheterization empowers them to maintain regular bladder emptying and prevent complications associated with urinary retention.

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The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which action should the nurse implement to reduce the risk of vesicant extravasation in the client who is receiving intravenous chemotherapy?

Correct Answer is C

Explanation

A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client's plan of care?

Correct Answer is D

Explanation

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