Nokea
Question 1 of 74
The nurse is caring for an 82-year-old male client admitted to the hospital for pneumonia. Which of the following findings may indicate a change in mental status?
Correct Answer:
Rationale:
Question 2 of 74
The nurse is caring for a client following cervical spinal surgery. Which of the following assessments would require follow-up?
Correct Answer:
Rationale:
Question 3 of 74
The following scenario applies to the next 1 items
The nurse is caring for a 71-year-old female in the emergency department (ED)
Item 1 of 1
Nurses' Note Diagnostics
1425: 71-year-old female arrives via EMS with a concern about a stroke. At approximately 1350 a client was at lunch with her family and suddenly stopped talking and fell to the right side. The client was unable to speak or follow verbal commands on the scene. Vital signs on arrival: 98.7° F (37.1° C), P 88, RR 18, BP 182/96. The client can blink her eyes and cannot follow verbal commands or express words. She is instructed to move each extremity but does not make any movement. Pupils are equal, round, and reactive to light. Right-sided facial drooping was noted. The client has a medical history of osteoarthritis, hypertension, and atrial fibrillation.
1427: A stroke alert was initiated at this time, and the client was transported to radiology for a STAT CT scan.
1438: Computed tomography scan completed. Physician at bedside evaluating the client and the results.
1444: Physician gave a verbal order for alteplase 0.9 mg/kg intravenous (IV) infuse over sixty minutes with a 10% alteplase bolus dosage given over one minute
The nurse reviews the nurses' note entries from 1425, 1427, 1438, and 1444 and plans care for this client indicated
For each potential nursing intervention, click to specify if the intervention is indicated or not Indicated:
The nurse is caring for a 71-year-old female in the emergency department (ED)
Item 1 of 1
Nurses' Note Diagnostics
1425: 71-year-old female arrives via EMS with a concern about a stroke. At approximately 1350 a client was at lunch with her family and suddenly stopped talking and fell to the right side. The client was unable to speak or follow verbal commands on the scene. Vital signs on arrival: 98.7° F (37.1° C), P 88, RR 18, BP 182/96. The client can blink her eyes and cannot follow verbal commands or express words. She is instructed to move each extremity but does not make any movement. Pupils are equal, round, and reactive to light. Right-sided facial drooping was noted. The client has a medical history of osteoarthritis, hypertension, and atrial fibrillation.
1427: A stroke alert was initiated at this time, and the client was transported to radiology for a STAT CT scan.
1438: Computed tomography scan completed. Physician at bedside evaluating the client and the results.
1444: Physician gave a verbal order for alteplase 0.9 mg/kg intravenous (IV) infuse over sixty minutes with a 10% alteplase bolus dosage given over one minute
The nurse reviews the nurses' note entries from 1425, 1427, 1438, and 1444 and plans care for this client indicated
Correct Answer:
Rationale:
Question 4 of 74
The nurse is discussing biological clocks with another nurse. What term is used to describe a human's innate biological clock relating to daytime and nighttime wakefulness and activity?
Correct Answer:
Rationale:
Question 5 of 74
The nurse is caring for a client with a basilar skull fracture. Which assessment finding requires immediate follow-up?
Correct Answer:
Rationale:
Upgrade for Full Access
Viewing 5 of 74 questions. Subscribe to unlock all content.
- Complete access to all questions
- Detailed explanations
- Progress tracking
Related Questions
- The nurse makes a note in the nurses' notes and reviews the diagnostic test results. Complete the sentence below from the list of options. The client...
- Click to specify if the assessment findings are consistent with cataracts or glaucoma: Increase in intraocular pressure (IOP)
- The nurse is preparing a staff in-service regarding sensorineural hearing loss. It would be appropriate for the nurse to identify which factors cause...
- The nurse is caring for a client newly prescribed ropinirole. The nurse understands that this medication is prescribed to treat which condition?
- The nurse is observing a client with epilepsy have a sudden loss of muscle tone that lasts for a few seconds. The nurse is correct in identifying this...