A nurse is assessing a patient who is experiencing dizziness and weakness. The nurse should prioritize which of the following?
- A. Blood pressure measurement.
- B. Pulse oximetry.
- C. Blood glucose levels.
- D. Cardiac monitoring.
Correct Answer: A
Rationale: The correct answer is A: Blood pressure measurement. Dizziness and weakness can be symptoms of hypotension or low blood pressure. Prioritizing blood pressure measurement is crucial because it can indicate if the patient is at risk of complications like cardiovascular collapse. Pulse oximetry (B) is important for assessing oxygen levels in the blood but may not directly address dizziness and weakness. Blood glucose levels (C) are important but not the priority in this scenario. Cardiac monitoring (D) may be necessary but should come after assessing blood pressure to rule out immediate life-threatening conditions.
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What should be the first intervention for a client suspected of having a stroke?
- A. Monitor neurological status
- B. Perform a CT scan
- C. Administer fibrinolytics
- D. Perform MRI
Correct Answer: B
Rationale: The correct first intervention for a client suspected of having a stroke is to perform a CT scan (Choice B). This is because a CT scan can quickly identify the type of stroke (ischemic or hemorrhagic) and guide treatment decisions. Monitoring neurological status (Choice A) can be important but does not provide a definitive diagnosis. Administering fibrinolytics (Choice C) should only be done after confirming the type of stroke to avoid complications. Performing an MRI (Choice D) is more time-consuming and may not be feasible in the acute setting where quick intervention is crucial. Therefore, a CT scan is the most appropriate initial intervention for a suspected stroke.
What should be the nurse's first action when caring for a client who has a suspected stroke?
- A. Assess the client's airway
- B. Administer oxygen
- C. Administer aspirin
- D. Perform a CT scan
Correct Answer: A
Rationale: The correct answer is A: Assess the client's airway. This is the first action because airway patency is the top priority in any emergency situation, including a suspected stroke. Ensuring the client can breathe effectively is crucial to prevent hypoxia and further complications. Administering oxygen (choice B) may be necessary after assessing the airway. Administering aspirin (choice C) should be done after a definitive diagnosis of an ischemic stroke. Performing a CT scan (choice D) is important for diagnosis but is not the first action to take in a suspected stroke scenario.
A patient keeps saying, "I feel hot. Hot, cot, rot, tot, got. I'm a spot.' This is an illustration of:
- A. Blocking.
- B. Clanging.
- C. Echolalia.
- D. Neologism.
Correct Answer: B
Rationale: The correct answer is B: Clanging. Clanging refers to the phenomenon where words are chosen based on sound rather than meaning. In this case, the patient's speech demonstrates a pattern of words that rhyme or have similar sounds, despite lacking coherence or logical connection. This behavior is commonly seen in individuals with conditions like schizophrenia.
Incorrect choices:
A: Blocking - Blocking refers to sudden interruption or cessation of speech. This does not apply to the scenario described.
C: Echolalia - Echolalia involves repetition of words or phrases spoken by others, not self-generated word patterns like in the scenario.
D: Neologism - Neologism refers to the creation of new words or phrases with unique meanings, which is not reflected in the patient's speech pattern.
What assessment framework provides additional modesty for clients, such as teenage girls?
- A. Body systems
- B. Functional
- C. Focused
- D. Head to toe
Correct Answer: D
Rationale: The correct answer is D: Head to toe. This assessment framework allows for modesty by assessing one body part at a time, starting from the head down to the toe. This approach ensures clients, especially teenage girls, feel comfortable and respected during the assessment process. Other choices like A (Body systems) involve assessing multiple body parts simultaneously, potentially compromising modesty. Functional assessment (B) focuses on assessing specific functions rather than individual body parts, which may not address the modesty concern. Focused assessment (C) targets a specific area of concern, which may not provide a comprehensive evaluation while also potentially overlooking modesty concerns.
What is the most appropriate action for a client with a history of asthma who is experiencing wheezing?
- A. Administer albuterol
- B. Administer antihistamines
- C. Monitor for signs of infection
- D. Administer epinephrine
Correct Answer: A
Rationale: The correct answer is A: Administer albuterol. Albuterol is a bronchodilator that helps open the airways, relieving wheezing in asthma patients. It is the first-line treatment for acute asthma exacerbations. Antihistamines (B) do not treat asthma symptoms. Monitoring for infection (C) is important but not the immediate action for wheezing. Epinephrine (D) is used for severe allergic reactions, not routine asthma management.