A nurse in an assisted living facility is collecting data from an older adult client who fell in their room and hit their head on the dresser. Which of the following findings is the nurse's priority?

Unable to remember their adult children's names.

Unable to remain fully awake while answering questions.

Unable to repeat the names of three common objects the nurse names.

Unable to answer a judgment question correctly.

Answer and Explanation

The Correct Answer is B

Choice A reason:
While memory lapses, such as being unable to remember their adult children's names, can be concerning, they are not the immediate priority following a head injury. Memory issues may result from various factors, including the emotional shock of the fall or pre-existing cognitive conditions.

Choice B reason:
The inability to remain fully awake, or altered levels of consciousness, is a critical sign that may indicate a serious brain injury, such as a concussion or hemorrhage. This finding requires urgent attention to prevent further complications, making it the nurse's priority.

Choice C reason:
Difficulty in repeating the names of three common objects could suggest cognitive impairment or confusion, which are concerning but secondary to consciousness and alertness issues. Cognitive assessments are part of a broader neurological evaluation following a head injury.

Choice D reason:
Incorrectly answering a judgment question is part of a cognitive assessment and, while important, does not take precedence over signs that may indicate a life-threatening condition, such as changes in consciousness.

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Correct Answer is C

Explanation

Choice A Reason:
Administering the feeding solution at a cold temperature is not recommended because it can cause discomfort and potentially lead to gastrointestinal symptoms such as cramping. The feeding solution should be at room temperature to ensure the comfort of the client and to prevent any unnecessary complications.

Choice B Reason:Typically, the tube is flushed with about 30 mL of water before and after feedings to ensure patency and prevent clogging, not 90 mL.

Choice C Reason:Elevating the head of the bed helps prevent aspiration and promotes proper digestion by using gravity to keep the feeding solution in the stomach or jejunum.

Choice D Reason:
Rotating the jejunostomy tube once per day is not a standard practice and is generally not recommended. Rotating the tube can cause irritation to the jejunum and may increase the risk of complications such as infection or dislodgement of the tube.

A. Having a total cholesterol level below 200 mg/dL increases my risk for a stroke. B. My provider might prescribe a glucocorticoid regimen to decrease my risk for a stroke. C. I can decrease my risk for a stroke by losing excess weight. D. My risk for a stroke increases if my HbA1c level is 6 percent or less.

Correct Answer is C

Explanation

Choice A reason:

Having a total cholesterol level below 200 mg/dL is actually considered desirable and does not increase the risk for a stroke. It is when the cholesterol level is high that the risk for atherosclerosis (plaque buildup in arteries) and consequently, stroke, increases. The American Heart Association recommends that total cholesterol levels should be less than 200 mg/dL to reduce the risk of heart disease and stroke.

Choice B reason:

Glucocorticoids are not typically prescribed to decrease the risk of stroke in patients with diabetes mellitus. In fact, glucocorticoids can increase blood glucose levels and potentially worsen diabetes control, which could indirectly increase the risk of stroke. Stroke prevention in diabetes focuses on controlling blood glucose, blood pressure, and cholesterol levels, as well as lifestyle modifications such as diet and exercise.

Choice C reason:

Losing excess weight is a recognized strategy for reducing the risk of stroke, especially in individuals with diabetes mellitus. Excess weight can contribute to high blood pressure, increased cholesterol levels, and poor blood glucose control, all of which are risk factors for stroke. Weight loss can improve these parameters and thus reduce the risk.

Choice D reason:

An HbA1c level of 6 percent or less is typically a goal in diabetes management to indicate good blood glucose control and does not increase the risk for a stroke. On the contrary, maintaining an HbA1c level within the target range helps reduce the risk of diabetes-related complications, including stroke.

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A nurse in an assisted living facility is collecting data from an older adult client who fell in their room and hit their head on the dresser. Which of the following findings is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving intermittent bolus enteral feedings through a jejunostomy tube. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client who has diabetes mellitus about reducing the risk for a stroke. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse on the oncology unit is evaluating a client's response after receiving a dose of aprepitant. Which of the following therapeutic effects should the nurse expect?

A nurse is reviewing the laboratory data of a client who is scheduled for a liver biopsy. Which of the following values should the nurse report to the provider?

A nurse is reinforcing discharge teaching with a client who has a new permanent pacemaker. Which of the following statements by the client indicates an understanding of the teaching?

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A nurse is preparing to perform tracheostomy care for a client. In which order should the nurse take the following steps? Use all the steps.

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A nurse is reinforcing discharge teaching for a client who had a cerebrovascular accident (CVA) and requires assistance to perform their activities of daily living (ADLs). Which of the following statements should the nurse provide?

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