Which are would be a priority of care for a patient who is being admitted to the hospital and its demonstrating signs of delirium?

Safety precaution

Oxygenation

Pain management

Infection

Answer and Explanation

The Correct Answer is A

A.   The priority in managing delirium is ensuring the patient's safety, as delirium increases the risk of falls, self-harm, and other dangerous behaviors. Close monitoring and protective measures are essential.
B.   Oxygenation is important but not the first priority unless the patient shows signs of hypoxia or respiratory distress.
C.   Pain management should be considered, but it is secondary to addressing the safety risks associated with delirium.
D.   Infection should be investigated, but the immediate concern in delirium is safety due to the altered mental state.

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Correct Answer is A

Explanation

A. Osmotic diuretics, such as mannitol, help reduce cerebral edema by drawing fluid out of the brain.
B. Osmotic diuretics do not increase cell size.
C. The goal of osmotic diuretics is not to provide fluid hydration.
D. The medication does not expand extracellular fluid volume; it reduces it.

A. "tPA should be administered within 12 hrs of the onset of a stroke." B. "tPA is administered by intraarterial infusion." C. "tPA is administered IV." D. "PA requires BP monitoring during and 24 hrs after the treatment."

Correct Answer is A

Explanation

A. tPA (tissue plasminogen activator) should be administered within 3 to 4.5 hours of the onset of ischemic stroke symptoms, not 12 hours. Administering it after this window increases the risk of complications such as bleeding.
B. tPA is administered by intraarterial infusion is true, but it refers to a specific technique for certain stroke types.
C. tPA is administered IV is correct for intravenous administration in many cases of ischemic stroke.

D. tPA requires BP monitoring during and 24 hrs after the treatment is accurate as blood pressure control is critical when administering tPA.

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Which are would be a priority of care for a patient who is being admitted to the hospital and its demonstrating signs of delirium?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication?

Correct Answer is A

Explanation

An RN is teaching a student nurse about tissue plasminogen activator (tPA) administration in a patient with ischemic stroke. Which statement made by the student nurse indicates a need for further teaching?

Correct Answer is A

Explanation

A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?

A nurse is teaching an older adult client who has diabetes mellitus about preventing the long- term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include?

A nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure?

A nurse caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take?

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?

A nurse is caring for a client who has meningitis, a temperature of 39.7° C (103.5° F), and is prescribed a hypothermia blanket. While using this therapy, the nurse should know that the client must carefully be observed for which of the following complications?

A nurse is assessing a client who has a score of 6 on the Glasgow Coma Scale. The nurse should expect which of the following outcomes based on this score?

Which outcome would concern the nurse when the patient's calculated mean arterial pressure (MAP) is below 70 mm Hg?