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What are the signs and symptoms of a hemorrhagic stroke?
- A. Sudden severe headache, decreased level of consciousness, and seizures
- B. Loss of consciousness and weakness
- C. Temporary vision loss
- D. Severe chest pain and shortness of breath
Correct Answer: A
Rationale: The correct answer is A. A hemorrhagic stroke often presents with a sudden severe headache, decreased level of consciousness, and seizures due to bleeding in the brain. Choice B, loss of consciousness and weakness, is more indicative of an ischemic stroke where a clot blocks blood flow to the brain. Choice C, temporary vision loss, is more commonly seen in conditions like transient ischemic attacks (TIAs) or retinal migraines. Choice D, severe chest pain and shortness of breath, are symptoms more associated with cardiac issues like a heart attack.
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What lab value should be monitored in a patient with HIV?
- A. CD4 T-cell count below 180 cells/mm3
- B. Serum albumin levels
- C. Hemoglobin levels
- D. White blood cell count
Correct Answer: A
Rationale: The correct answer is A: CD4 T-cell count below 180 cells/mm3. Monitoring the CD4 T-cell count is crucial in patients with HIV as it indicates the level of immunocompromise. A CD4 T-cell count below 180 cells/mm3 signifies severe immunosuppression and an increased risk of opportunistic infections. Serum albumin levels (choice B) are important for nutritional status assessment but not specific to HIV monitoring. Hemoglobin levels (choice C) are important for assessing anemia but do not directly reflect HIV disease progression. White blood cell count (choice D) is a general marker of inflammation and infection, but monitoring CD4 T-cell count is more specific and crucial in managing HIV.
What should a healthcare professional monitor for in a patient with compartment syndrome?
- A. Unrelieved pain, pallor, and pulselessness
- B. Localized redness and swelling
- C. Fever and signs of infection
- D. Loss of deep tendon reflexes
Correct Answer: A
Rationale: Unrelieved pain, pallor, and pulselessness are classic signs of compartment syndrome. In this condition, increased pressure within a muscle compartment impairs blood flow, leading to severe pain that is not relieved by usual measures, pallor from decreased blood flow, and pulselessness due to compromised circulation. These signs indicate a medical emergency requiring immediate intervention. Localized redness and swelling (Choice B) are more characteristic of inflammation or infection rather than compartment syndrome. Fever and signs of infection (Choice C) are not typical manifestations of compartment syndrome. Loss of deep tendon reflexes (Choice D) is associated with conditions affecting the nervous system, not compartment syndrome.
A patient is admitted with chest pain, possible acute coronary syndrome. What should the nurse do first?
- A. Administer sublingual nitroglycerin
- B. Get IV access
- C. Obtain cardiac enzymes
- D. Auscultate heart sounds
Correct Answer: A
Rationale: In a patient with chest pain, possible acute coronary syndrome, the nurse should administer sublingual nitroglycerin first. Nitroglycerin helps to vasodilate coronary arteries, improving blood flow to the heart, and reducing cardiac workload. This can alleviate chest pain and decrease cardiac tissue damage in acute coronary syndrome. Getting IV access, obtaining cardiac enzymes, and auscultating heart sounds are important steps in the assessment and management of acute coronary syndrome, but administering nitroglycerin to relieve chest pain and improve blood flow takes precedence as it directly addresses the patient's symptoms and aims to prevent further cardiac damage.
What is the priority intervention for a patient with unstable angina?
- A. Administer nitroglycerin
- B. Establish IV access
- C. Auscultate heart sounds
- D. Administer aspirin
Correct Answer: A
Rationale: The correct answer is to administer nitroglycerin. Nitroglycerin is the priority intervention for a patient with unstable angina as it helps dilate blood vessels, improve blood flow to the heart, relieve chest pain, and prevent further cardiac damage. Establishing IV access (choice B) may be important but is not the priority over administering nitroglycerin in this scenario. Auscultating heart sounds (choice C) and administering aspirin (choice D) are also important aspects of managing unstable angina, but they are not the immediate priority intervention when a patient is experiencing chest pain.
What dietary changes should a patient with GERD make to manage their symptoms?
- A. Avoid mint and spicy foods
- B. Eat large, frequent meals
- C. Consume liquids with meals
- D. Eat small, frequent meals
Correct Answer: A
Rationale: The correct answer is A: Avoid mint and spicy foods. Patients with GERD should avoid foods like mint and spicy dishes as they can trigger symptoms by increasing gastric acid secretion. Choices B, C, and D are incorrect. Eating large, frequent meals can exacerbate GERD symptoms by putting more pressure on the lower esophageal sphincter, consuming liquids with meals can lead to increased reflux, and eating small, frequent meals is the recommended approach to reduce symptoms and manage GERD.