A client presents to the emergency department complaining of headaches and blurred vision. The client's vital signs are as follows, Pulse 102 beats/minute, BP 172/92. RR 20 breaths/minute, SpO2.97% on room air temperature of 98.64. Which of the following interventions would be most appropriate for this patient?

Administer IV hydralazine and monitor blood pressure

Administer oxygen at 10 liters/minute by non rebreather mask

Administer acetaminophen 650 mg PO re-check temperature

Infuse 0.9% sodium chioride at 120 mL/hour

Answer and Explanation

The Correct Answer is A

A) "Administer IV hydralazine and monitor blood pressure":
. The patient's elevated blood pressure (172/92 mmHg), along with headaches and blurred vision, could indicate a hypertensive emergency, a serious condition where extremely high blood pressure can cause acute organ damage. Hydralazine is a common intravenous antihypertensive medication used to lower blood pressure quickly in these situations. The nurse should administer hydralazine as prescribed and closely monitor the blood pressure to prevent complications like stroke, heart failure, or kidney damage. Blood pressure management is the priority, as the patient's symptoms are likely related to the elevated BP.

B) "Administer oxygen at 10 liters/minute by non-rebreather mask":
. While oxygen therapy may be appropriate for patients with respiratory distress or hypoxia, the patient's SpO2 is 97% on room air, indicating that there is no immediate oxygenation issue. Administering oxygen unnecessarily could lead to oxygen toxicity, and it is not the priority in this case. The patient's main concern is their elevated blood pressure, which requires urgent management.

C) "Administer acetaminophen 650 mg PO re-check temperature":
. While headaches are one of the patient's complaints, there is no indication of fever (the temperature is 98.6°F). Administering acetaminophen would be appropriate for pain relief, but it is not the priority in this case. The elevated blood pressure and potential hypertensive emergency are the primary issues that need to be addressed first.

D) "Infuse 0.9% sodium chloride at 120 mL/hour":
. Normal saline (0.9% sodium chloride) is typically used for hydration, but there is no indication that the patient is dehydrated or that intravenous fluids are the priority. In cases of hypertensive emergency, the goal is to lower blood pressure using antihypertensive medications, not to infuse fluids. Fluid administration could potentially worsen the situation if the elevated blood pressure is not addressed first.

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Correct Answer is B

Explanation

A. Sedate the client with PRN medications so they stay in bed:
Sedating a client to prevent movement is not an appropriate intervention for fall prevention. This approach could have adverse effects, such as increased confusion, sedation, and even a greater risk for falls once the medication wears off. It may also contribute to a decreased level of independence and quality of life for the client. Non-pharmacological interventions such as environmental modifications and supportive devices should be prioritized.

B. Implement the bed alarm and call light system:
Implementing a bed alarm and call light system is an effective and appropriate strategy to prevent falls in an older adult client. The bed alarm alerts the healthcare team when the client attempts to get out of bed, reducing the risk of falls. The call light allows the client to request assistance before attempting to move independently, ensuring timely support and reducing fall risk. This intervention promotes safety while maintaining the client’s autonomy.

C. Ensure all four side rails on the bed are up:
While side rails may prevent a client from falling out of bed, raising all four side rails can increase the risk of injury. Clients may try to climb over the rails, which can lead to entrapment or falls. In addition, side rails can create a false sense of security and reduce the client's ability to mobilize independently. A more appropriate measure would be using one or two side rails or providing assistance with repositioning or transferring when necessary.

D. Avoid night lights in the client's room to promote sleep:
Avoiding night lights is not advisable for older adults, particularly those at risk for falls. A dark environment can increase confusion and disorientation, leading to unsafe movements. Providing soft night lights in the room can enhance visibility during nighttime hours, reducing the likelihood of accidents and falls when the client needs to get up to use the bathroom or reposition. Adequate lighting is a key aspect of fall prevention.

A. Complete blood count (CBC) B. Electroencephalogram (EEG) C. Computed tomography (CT) scan D. Chest radiograph (chest x-ray)

Correct Answer is C

Explanation

A) "Complete blood count (CBC)":
. A CBC can provide important information about the patient's overall health, including potential signs of infection, anemia, or other underlying conditions. However, in the context of acute neurological symptoms such as left-sided weakness, CT scan is the priority test because it will help quickly determine if there is an acute neurological event, such as a stroke or hemorrhage. While a CBC might be useful later to assess for underlying
conditions or potential causes, it is not the first test to perform in this scenario.

B) "Electroencephalogram (EEG)":
. An EEG is primarily used to diagnose and assess seizure activity or epileptic disorders. While seizures can cause neurological deficits, the patient's sudden onset of left-sided weakness is more suggestive of a stroke, not a seizure. The priority is to rule out stroke with a CT scan, not to assess for seizures with an EEG.

C) "Computed tomography (CT) scan":
. A CT scan is the first diagnostic test to perform in patients with acute neurological deficits such as sudden-onset weakness, especially when a stroke is suspected. A CT scan can quickly detect if the cause is an ischemic stroke (lack of blood flow due to a clot) or a hemorrhagic stroke (bleeding in the brain). Time is critical in the management of stroke, as early intervention with treatments like tPA (tissue plasminogen activator) for ischemic stroke can greatly improve outcomes. The CT scan can help determine if the patient is a candidate for thrombolysis or if other interventions are needed.

D) "Chest radiograph (chest x-ray)":
. While a chest x-ray can be useful for diagnosing respiratory issues, such as pneumonia or congestion, it is not helpful in evaluating the cause of acute neurological symptoms like left-sided weakness. The priority test is a CT scan to evaluate the brain and rule out conditions like stroke or hemorrhage, not a chest x-ray.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for an older adult client who is at risk for falls. Which of the following interventions should be included in the plan of care for this client?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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