Nokea
What is the priority nursing action for a client with a suspected stroke?
- A. Administer oxygen
- B. Administer aspirin
- C. Administer thrombolytics
- D. Place the client in a supine position
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. Oxygenation is the priority in stroke management to ensure adequate oxygen supply to the brain. Oxygen therapy can help reduce hypoxia, which is crucial in the acute phase of a stroke. Administering aspirin (B) is important but comes after ensuring oxygenation. Administering thrombolytics (C) requires proper assessment and diagnostic confirmation, not an immediate priority. Placing the client in a supine position (D) may worsen stroke symptoms if there is compromised blood flow, so it is not recommended as the initial action.
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A patient tells the nurse that he is very nervous, that he is nauseated, and that he "feels hot." This type of data would be:
- A. objective.
- B. reflective.
- C. subjective.
- D. introspective.
Correct Answer: C
Rationale: The correct answer is C: subjective. Subjective data refers to information provided by the patient based on their feelings, perceptions, and experiences. In this case, the patient's report of feeling nervous, nauseated, and hot is subjective because it reflects their personal sensations and cannot be measured or observed directly by the nurse. Objective data (choice A) is measurable and observable, such as vital signs or physical examination findings. Reflective (choice B) and introspective (choice D) do not accurately describe the type of data provided by the patient in this scenario. The patient's symptoms are subjective because they are based on the patient's own feelings and experiences, making choice C the most appropriate answer.
The nurse is conducting a physical assessment. The data the nurse would collect vary depending on what?
- A. How much time the nurse has
- B. The client's acuity
- C. The client's cooperation
- D. Onset of current symptoms
Correct Answer: B
Rationale: Step 1: The nurse should prioritize collecting data based on the client's acuity to address immediate needs and ensure patient safety.
Step 2: Acuity determines the urgency and intensity of care required, guiding the assessment focus.
Step 3: Time available or client cooperation may influence the depth of assessment but do not dictate the data collected.
Step 4: The onset of symptoms is important for history-taking but not the primary factor in determining assessment data.
Which intervention should the nurse implement for a client who is experiencing a seizure?
- A. Place the client on their side and protect their head
- B. Loosen the client's clothing and ensure safety
- C. Monitor the client's airway and give oxygen
- D. Administer antiepileptic medications
Correct Answer: D
Rationale: The correct answer is D, administering antiepileptic medications. This is because during an active seizure, the priority is to stop the seizure activity. Antiepileptic medications are specifically designed to prevent or reduce the frequency and intensity of seizures. Placing the client on their side and protecting their head (choice A) is important for safety but does not address stopping the seizure. Loosening clothing and ensuring safety (choice B) is also important but does not directly address the seizure itself. Monitoring airway and giving oxygen (choice C) is crucial but does not actively stop the seizure. Therefore, administering antiepileptic medications is the most appropriate intervention to address the root cause of the seizure.
Which is included only in a comprehensive assessment?
- A. Circulatory assessment
- B. Assessment of the airway
- C. Complete health history
- D. Disability assessment
Correct Answer: C
Rationale: The correct answer is C: Complete health history. In a comprehensive assessment, obtaining a complete health history is essential to gather information about the patient's past and present health conditions, including medical history, family history, social history, and current symptoms. This information helps the healthcare provider understand the patient's overall health status, identify risk factors, and develop an appropriate treatment plan. Assessing the circulatory system (A) and airway (B) are important components of a physical assessment, but they alone do not constitute a comprehensive assessment. Disability assessment (D) focuses on the functional limitations caused by a disability and is not always included in a comprehensive health assessment.
What term describes excessive stretching of a ligament, as seen in a client with a pulled ligament?
- A. sprain
- B. strain
- C. subluxation
- D. distortion
Correct Answer: B
Rationale: The correct answer is B: strain. A strain refers to excessive stretching or tearing of a muscle or tendon, not a ligament. A sprain (choice A) is the correct term for excessive stretching of a ligament. Subluxation (choice C) refers to partial dislocation of a joint, not a ligament injury. Distortion (choice D) is a general term that does not specifically describe ligament stretching. Therefore, the correct term for excessive stretching of a ligament is a sprain, making choice A the correct answer.