Nokea
A nurse in the emergency department is caring for a client who had a seizure and became unresponsive after stating they had a sudden, severe headache. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38.2° C (100.8° F). Which of the following neurological disorders should the nurse suspect?
- A. Embolic stroke
- B. Thrombotic stroke
- C. Transient ischemic attack (TIA)
- D. Hemorrhagic stroke
Correct Answer: D
Rationale: The sudden severe headache followed by seizure and unresponsiveness with elevated BP suggests hemorrhagic stroke.
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A nurse is assessing a client and discovers the infusion pump with the client's total parenteral nutrition (TPN) solution is not infusing. The nurse should monitor the client for which of the following clinical manifestations?
- A. Fever and chills
- B. Hypertension and crackles
- C. Excessive thirst and urination
- D. Shakiness and diaphoresis
Correct Answer: D
Rationale: These are signs of hypoglycemia from sudden TPN interruption.
A nurse is assessing a client who has chronic kidney disease for fluid volume increase. Which of the following provides a reliable measure of fluid retention?
- A. Sodium level
- B. Intake and output
- C. Daily weight
- D. Tissue turgor
Correct Answer: C
Rationale: Daily weight is the most reliable measure of fluid retention as 1 kg weight gain equals approximately 1 liter fluid retention.
A nurse is assessing a client who has an obstruction of the common bile duct resulting from chronic cholecystitis. Which of the following findings should the nurse expect?
- A. Tenderness in the left upper abdomen
- B. Ecchymosis of the extremities
- C. Pale-colored urine
- D. Fatty stools
Correct Answer: D
Rationale: Fatty stools (steatorrhea) occur with common bile duct obstruction because bile cannot reach the intestine to emulsify fats.
A nurse is preparing to instill 840 mL of enteral nutrition via a client's gastrostomy tube over a 24-hour period using an infusion pump. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 35
Rationale: Calculation: 840 mL ÷ 24 hours = 35 mL/hr
A client arrives at the emergency room with symptoms of peptic ulcer disease. Which of these symptoms should the nurse identify as the priority?
- A. Hematemesis
- B. Abdominal bloating
- C. Epigastric discomfort
- D. Dyspepsia
Correct Answer: A
Rationale: Hematemesis indicates active bleeding and is the most urgent concern.