Nokea
A client with a suspected stroke is admitted to the emergency department. What is the nurse's priority action?
- A. Administer aspirin as ordered.
- B. Assess neurological status.
- C. Prepare for a CT scan.
- D. Monitor blood pressure.
Correct Answer: B
Rationale: Assessing neurological status is the priority to establish a baseline and detect changes in a suspected stroke, guiding urgent interventions.
You may also like to solve these questions
During a clinic visit for a postpartum examination, the mother of a 2-week-old infant tearfully tells the nurse she feels very tired and thinks she is not a good mother to her baby. Which statement by the nurse would be best?
- A. The hormonal changes your body is experiencing are causing you to feel this way.'
- B. Most new mothers feel the same way that you do. I hear that a lot from others.'
- C. You need to have your husband and family help you so that you can get some rest.'
- D. I'm concerned about what you are experiencing. Tell me more about what you are thinking and feeling.'
Correct Answer: D
Rationale: Acknowledging the mother's feelings and encouraging her to elaborate promotes therapeutic communication and helps assess for postpartum depression or other concerns. Attributing feelings solely to hormones, normalizing without exploration, or suggesting family help without assessment may miss underlying issues.
A client has been diagnosed with right-sided heart failure. The nurse should assess the client further for:
- A. Intermittent claudication.
- B. Dyspnea.
- C. Dependent edema.
- D. Crackles.
Correct Answer: C
Rationale: Dependent edema is a key sign of right-sided heart failure, as the heart fails to pump blood effectively, causing fluid backup in the extremities.
A client with metastatic cancer of the liver is concerned about his progress. Which of the following nursing interventions is most appropriate?
- A. Provide information for the client to consider a liver transplantation.
- B. Assure the client that the prescribed medications will shrink all tumor sites.
- C. Explain the effects of chemotherapy.
- D. Place emphasis on providing symptomatic and comfort measures.
Correct Answer: D
Rationale: For metastatic liver cancer, palliative care focusing on symptom relief and comfort is most appropriate, as transplantation or tumor shrinkage may not be feasible.
You are working as a wound care nurse. You measure the size of a client's wound and it is 3 cm deep, 2 cm long and 4 cm wide. You would document the dimension of this wound as:
- A. 6 cm
- B. 12 cm
- C. 20 cm
- D. 24 cm
Correct Answer: B
Rationale: Wound dimensions are typically documented as length x width x depth (2 cm x 4 cm x 3 cm), but based on options, 12 cm may reflect a calculation error; correct documentation is individual measurements.
A client with a diagnosis of gout is prescribed indomethacin. The nurse should instruct the client to:
- A. Take the medication with food to reduce stomach upset.
- B. Avoid drinking alcohol.
- C. Limit fluid intake.
- D. Take the medication at bedtime only.
Correct Answer: A,B
Rationale: Taking indomethacin with food reduces gastrointestinal upset, and avoiding alcohol prevents uric acid buildup.