Nokea
After completing a thorough neurological and physical assessment of a patient who is admitted for a suspected stroke, the medical-surgical nurse anticipates the next step in the immediate care of this patient will include
- A. administering tissue plasminogen activator.
- B. obtaining a CT scan of the head without contrast.
- C. obtaining a neurosurgical consultation.
- D. preparing for carotid Doppler ultrasonography.
Correct Answer: B
Rationale: A CT scan is essential to differentiate between ischemic and hemorrhagic stroke.
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What is a common cause of sensorineural hearing loss?
- A. Otitis media
- B. Temporal bone fractures
- C. Otitis externa
- D. Vascular conditions
Correct Answer: D
Rationale: Vascular conditions impair blood supply to the cochlea, causing sensorineural hearing loss.
A client with end-stage renal disease (ESRD) is receiving hemodialysis. Which assessment finding indicates a need for immediate action?
- A. Weight gain of 1 kg since the last dialysis session
- B. Blood pressure of 150/90 mm Hg
- C. Potassium level of 6.5 mEq/L
- D. Hemoglobin level of 10 g/dL
Correct Answer: C
Rationale: The correct answer is C: Potassium level of 6.5 mEq/L. High potassium levels in ESRD patients can lead to life-threatening cardiac arrhythmias. Immediate action is needed to prevent complications. A: Weight gain may indicate fluid retention, but it's not an immediate concern. B: Blood pressure is elevated but not an urgent issue. D: Hemoglobin level of 10 g/dL is within the acceptable range for ESRD patients and does not require immediate action.
You anticipate that the physician will order which drug for status epilepticus?
- A. PO phenytoin and carbamazepine
- B. IV lorazepam (Ativan)
- C. IV carbamazepine
- D. IV magnesium sulfate
Correct Answer: B
Rationale: Lorazepam is commonly used for rapid control of seizures in status epilepticus.
A client with a long history of smoking is being assessed by a nurse. Which finding is a common complication of chronic obstructive pulmonary disease (COPD)?
- A. Decreased anteroposterior chest diameter
- B. Increased breath sounds
- C. Prolonged expiratory phase
- D. Increased chest expansion
Correct Answer: C
Rationale: Step-by-step rationale:
1. COPD is characterized by airway obstruction, leading to difficulty exhaling.
2. Prolonged expiratory phase is a common finding due to air trapping.
3. This leads to hyperinflation and increased residual volume.
4. Decreased anteroposterior chest diameter is not typical in COPD.
5. Increased breath sounds and chest expansion are not common in COPD.
In summary, choice C is correct because it directly relates to the pathophysiology of COPD, while the other choices are not consistent with the condition.
In developing a discharge plan for a patient requiring home-care services, what is important to assess?
- A. Patient’s nursing diagnosis
- B. Availability of needed community services
- C. Patient’s functional abilities
- D. Patient’s family dynamics
Correct Answer: B
Rationale: Ensuring access to necessary community services is vital for successful home care.