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A patient is hospitalized following a stroke. Three days after admission, the patient is able to converse clearly with the nurse during the morning assessment. Early in the afternoon, the patient's daughter runs out of the room and says, "My mother can't talk. Somebody help!" Which response by the nurse is best?
- A. Explain to the daughter that this is not uncommon, esp. in the afternoon when the patient is tired from the morning care activities.
- B. Do a quick assessment to confirm the change in the patient's status, then notify the RN or physician.
- C. Call the speech therapist to come and to do a comprehensive speech assessment.
- D. Show the daughter how to do the speech exercises with her mother that were provided by the therapist
Correct Answer: B
Rationale: The best response by the nurse in this situation would be to do a quick assessment to confirm the change in the patient's status and then notify the registered nurse (RN) or physician. It is essential for the healthcare team to promptly assess and address any sudden changes in a stroke patient's condition, such as the sudden inability to speak. This could indicate a serious issue that requires immediate attention and intervention. By quickly assessing the patient's status and notifying the appropriate healthcare provider, the nurse can ensure that the patient receives the necessary care and interventions in a timely manner.
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A client with supraglottic cancer undergoes a partial laryngectomy. Postoperatively, a cuffed tracheostomy tube is in place. When removing secretions that pool above the cuff, the nurse should instruct the client to:
- A. Cough as the cuff is being deflated
- B. Hold the breath as the cuff is being re-inflated
- C. Take a deep breath as the nurse deflates the
- D. Exhale deeply as the nurse re-inflates the cuff cuff
Correct Answer: D
Rationale: The correct instruction for the client when removing secretions above the cuff of a tracheostomy tube is to exhale deeply as the nurse re-inflates the cuff. By having the client exhale deeply during cuff inflation, it helps to prevent aspiration of secretions or air into the lungs. This action also helps in securing an airtight seal around the tracheostomy tube before the normal breathing is resumed. It is crucial to promote the safety and prevent complications in clients with a tracheostomy tube, especially post partial laryngectomy.
A child with a poor nutritional status and weight loss is at risk for a negative nitrogen balance. To help diagnose this problem, the nurse in charge anticipates that the doctor will order which laboratory test?
- A. Total iron-binding capacity
- B. Hemoglobin
- C. Total protein
- D. Serum transferrin
Correct Answer: C
Rationale: Total protein is a laboratory test that is commonly ordered to assess the nutritional status of an individual. In the case of a child with poor nutritional status and weight loss, assessing the total protein levels can help in diagnosing a negative nitrogen balance. Total protein levels may decrease in individuals with inadequate protein intake, malnutrition, or negative nitrogen balance. Monitoring total protein levels can provide valuable information about the child's nutritional status and help guide further interventions to improve their overall health and well-being.
A 13-year-old is worried because his breasts are growing and are tender. What should the nurse tell him?
- A. We will draw blood to determine the cause.
- B. It is a slight hormonal imbalance that can be corrected with medication.
- C. It is a normal condition of puberty (gynecomastia) that usually resolves within a year or two.
- D. It is a rare finding in boys during puberty.
Correct Answer: C
Rationale: Gynecomastia and breast tenderness occur in about one-third of boys during mid-puberty and usually resolve within 2 years.
Which action by the nurse is appropriate?
- A. Observe the patient for abnormal bleeding.
- B. Notify the physician and expect an order to increase the warfarin dose.
- C. Advise the patient to double today's dose of warfarin.
- D. Administer Vit. K per protocol.
Correct Answer: A
Rationale: The appropriate action by the nurse is to observe the patient for abnormal bleeding. Warfarin is an anticoagulant medication, and one of its serious side effects is excessive bleeding. It is important for the nurse to monitor the patient closely for signs of abnormal bleeding, such as easy bruising, blood in urine or stool, or prolonged bleeding from cuts or wounds. This observation allows for early detection and intervention if any abnormal bleeding occurs. Notifications to the healthcare provider should also be made if abnormal bleeding is suspected. It is crucial not to make any changes to the warfarin dose or administer Vitamin K without a physician's order, as these actions can have serious consequences.
A patient complains of tingling in his fingers. He has positive Trousseau's and Chvostek's signs. He says that he feels depressed. Choose the most likely serum calcium (Ca ) value for this patient:
- A. 11mg/dl
- B. 7mg/dl
- C. 9mg/dl
- D. 5mg/dl
Correct Answer: A
Rationale: The patient's symptoms of tingling in the fingers, positive Trousseau's and Chvostek's signs, and feeling depressed are suggestive of hypocalcemia, which is commonly associated with low serum calcium levels. In this case, the most likely serum calcium value would be below the normal range, which is around 8.5-10.5 mg/dl. Among the given choices, an extremely low calcium value of 5mg/dl (Choice D) would be more consistent with severe hypocalcemia presenting with tetany and other neuromuscular symptoms rather than depression and mild symptoms. On the other hand, a high calcium level of 11mg/dl (Choice A) would indicate hypercalcemia, which can lead to neuropsychiatric symptoms like depression, as seen in this patient's presentation. Therefore, Choice A (11mg/dl) is the most likely serum calcium value for