Nokea
The nurse is caring for a client who reports a sudden, severe headache, and facial numbness. The nurse asks the client to smile and observes an uneven smile with facial droop to the right side and a hand grasp strength that is weaker on the right than the left. The client denies a recent history of headaches or trauma. Which intervention should the nurse perform in the immediate management of the client?
- A. Verify prescribed laboratory tests include prothrombin time and platelet count.
- B. Administer aspirin to prevent further clot formation and platelet clumping.
- C. Maintain elevated positioning of the dependent joints on affected side.
- D. Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.
Correct Answer: D
Rationale: IV catheters and fibrinolytic criteria review are critical for potential thrombolytic therapy in suspected ischemic stroke.
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A client with bilateral carpal tunnel syndrome reports to the nurse that the pain and tingling experienced worsens at night. Which client teaching should the nurse provide?
- A. Notify the healthcare provider as soon as possible.
- B. Wear braces on both wrists during the night.
- C. Elevate the hands on two pillows at night.
- D. Apply cold compresses for 30 minutes before bedtime.
Correct Answer: B
Rationale: Wrist braces maintain a neutral position, reducing median nerve pressure and alleviating nighttime symptoms.
Orders
Laboratory Results
Day 1, 1000
Serum uric acid, blood urea nitrogen (BUN), creatinine (Cr)
X-ray of right foot
Day 1, 1015
Acetaminophen 650 mg PO now
Based on the client's laboratory findings, the nurse recognizes that the client is having an acute gout attack and is most at risk for SwellingBruisingInfectionInflammationRash and DiscolorationErythemaCyanosisPallorEcchymosis in his affected joint.
- A. Inflammation
- B. Discoloration
- C. Erythema Cyanosis
- D. Swelling
- E. Bruising
Correct Answer: A,B
Rationale: Inflammation and discoloration are hallmark symptoms of gout due to urate crystal-induced immune response and increased blood flow.
History and Physical
Nurses’ notes
Laboratory Results
Flow Sheet
The nurse is caring for a client who was admitted to the hospital with reports of shortness of breath, fever, fatigue, and oral thrush three days ago. The health care provider reviews the laboratory and diagnostic tests with the client and informs of the diagnosis of Pneumocystis pneumonia. The client reports that they recently tested HIV positive. The nurse reviews the client's medical record.
HIV diagnosed 4 months ago with no medications prescribed.
Note added to H&P reporting client wishes to be confidential since family and friends are unaware of the HIV diagnosis
What order(s) should the nurse anticipate being prescribed after an update is reported to the healthcare providers? Select all that apply.
- A. Administer antiemetic
- B. Monitor for adverse reaction to antibiotics
- C. Increase IV fluids to 150 mL/hr
- D. Initiate airborne isolation
- E. Repeat CD4+ T-cell count STAT
Correct Answer: A,B,C
Rationale: Antiemetics , antibiotic monitoring , and increased fluids address emesis, treatment safety, and hydration in Pneumocystis pneumonia.
After falling down the basement steps, a client is brought to the emergency department. X-ray results confirm that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?
- A. Increased temperature to lower extremity.
- B. Circumferential edema of right foot.
- C. Right foot pale with sluggish capillary refill.
- D. Reports throbbing right leg pain.
Correct Answer: C
Rationale: Pale foot with sluggish capillary refill indicates compromised circulation, risking tissue ischemia requiring urgent intervention.
A client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client?
- A. Bradycardia and constipation.
- B. Lethargy and lack of appetite.
- C. Muscle cramping and dry, flushed skin.
- D. Palpitations and shortness of breath.
Correct Answer: D
Rationale: Palpitations and shortness of breath indicate hyperthyroidism from excessive levothyroxine, requiring dosage adjustment.