A nurse is assessing a client presenting with sudden onset confusion and weakness in the emergency department.

For each planned action, indicate whether it is anticipated or contraindicated in the client’s care.

Encourage client to ambulate independently to the bathroom

Monitor neurological status closely

Administer prescribed IV fluids to maintain hydration

Place the client in Trendelenburg position

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

This question focuses on prioritizing safe nursing interventions for a client presenting with sudden confusion, weakness, hypotension, and disorientation. These findings suggest impaired cerebral perfusion, possible dehydration, or an acute neurological or systemic event. Nursing care prioritizes safety, close neurological monitoring, and restoring circulating volume. Interventions that increase fall risk or worsen cerebral perfusion are contraindicated.

Rationale:

• Encourage client to ambulate independently to the bathroom: The client is confused, disoriented, and weak, placing them at high risk for falls and injury. Independent ambulation is unsafe because impaired cognition and hypotension reduce balance and coordination. The client requires assistance and fall precautions should remain in place. Therefore, encouraging independent ambulation is contraindicated.

• Monitor neurological status closely: Sudden confusion and disorientation indicate possible acute neurological or systemic compromise. Frequent neurological assessments help detect worsening mental status, stroke progression, or metabolic imbalance. Early identification of changes allows rapid intervention. This is a priority nursing action.

• Administer prescribed IV fluids to maintain hydration: The client’s low blood pressure (96/60 mmHg) and dry skin suggest possible hypovolemia contributing to decreased cerebral perfusion and confusion. IV fluids help restore circulating volume, improve blood pressure, and enhance tissue perfusion. This intervention supports stabilization of hemodynamic status. It is an appropriate and expected treatment.

• Place the client in Trendelenburg position: Trendelenburg positioning is no longer recommended for hypotension because it can reduce lung expansion and increase intracranial pressure. It may also worsen respiratory function and does not reliably improve cerebral perfusion. Safer alternatives include supine positioning with leg elevation if needed. Therefore, this position is contraindicated in this client.

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Correct Answer is C

Explanation

Assist-control (A/C) mechanical ventilation is a mode used to support clients who require full or partial respiratory assistance. In this mode, the ventilator delivers a preset tidal volume or pressure for every breath, whether it is triggered by the client or initiated by the machine. The set respiratory rate ensures a minimum number of breaths, while any additional spontaneous breaths initiated by the client are also fully supported. This mode ensures adequate ventilation while allowing the client some control over breathing frequency.

Rationale:
A. The client has achieved full control of their ventilation and can stop using the ventilator is incorrect because assist-control ventilation is still providing full respiratory support. The presence of spontaneous breaths does not indicate readiness for weaning or discontinuation. The ventilator remains essential in ensuring adequate oxygenation and ventilation.

B. The ventilator will not provide any assistance if the client's breathing is above the set rate is incorrect because in assist-control mode, every spontaneous breath triggered by the client is fully supported. Each breath receives the preset tidal volume or pressure, regardless of whether it exceeds the baseline respiratory rate. This ensures consistent ventilatory support even with increased patient effort.

C. The ventilator will assist every breath initiated by the client at whatever rate they choose is correct because assist-control ventilation delivers a full mechanical breath with each patient-triggered effort. The machine ensures both minimum ventilation and full support of spontaneous breaths. This allows the client to increase their respiratory rate without losing ventilatory assistance.

D. The ventilator will adjust the set rate to match the client's spontaneous breathing rate is incorrect because assist-control ventilation does not self-adjust based on patient effort. The preset rate remains constant, and spontaneous breaths are added on top of it. Any adjustments to settings must be made manually by the healthcare provider based on clinical assessment.

A. Continue with normal activity and avoid resting. B. Call for emergency medical assistance before taking a second tablet. C. Take two more sublingual tablets at the same time to expedite relief. D. Stop all medications if the pain does not subside with the first tablet. E. Take a third sublingual tablet if the pain is still not relieved after the second tablet and 5 minutes have passed.

Correct Answer is ["B","E"]

Explanation

Management of acute angina with sublingual Nitroglycerin requires prompt action to restore myocardial oxygen balance and prevent progression to myocardial infarction. Nitroglycerin works by causing vasodilation, which decreases cardiac workload and improves coronary blood flow. Standard teaching includes stopping activity, resting, and taking one tablet at the onset of chest pain. If pain persists after the first dose, emergency intervention and additional doses must follow a specific safe sequence.

Rationale:
A. Continuing normal activity is inappropriate because physical exertion increases myocardial oxygen demand and can worsen ischemia. The client should immediately stop activity and rest in a sitting or lying position to reduce cardiac workload. Rest enhances the effect of nitroglycerin and helps prevent worsening chest pain or progression to infarction.

B. Calling for emergency medical assistance before taking the second tablet is correct because persistent chest pain after the first dose may indicate unstable angina or myocardial infarction. Emergency services should be contacted after 5 minutes if pain is not relieved. Prompt medical evaluation is critical since delayed treatment increases the risk of permanent myocardial damage.

C. Taking two more tablets at the same time is unsafe and not recommended. Nitroglycerin should be administered one tablet every 5 minutes, up to a maximum of three doses. Taking multiple tablets simultaneously increases the risk of severe hypotension, dizziness, and syncope without improving safety or effectiveness.

D. Stopping all medications is incorrect and potentially dangerous. The client should continue prescribed cardiovascular medications unless specifically instructed otherwise by the provider. Abrupt discontinuation of drugs such as beta blockers, antiplatelets, or antihypertensives can worsen cardiac instability and increase the risk of complications.

E. Taking a third sublingual tablet after another 5 minutes is correct if chest pain persists after the second dose. The standard protocol allows one tablet every 5 minutes for a total of three doses while awaiting emergency help. Continued pain after the third dose strongly suggests a serious cardiac event requiring immediate advanced treatment.

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A nurse is assessing a client presenting with sudden onset confusion and weakness in the emergency department. For each planned action, indicate whether it is anticipated or contraindicated in the client’s care.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receiving assist control mechanical ventilation has a respiratory rate set to 14 breaths per minute. The nurse observes that the client is initiating breaths that are above the preset rate. What is the most appropriate interpretation of this situation?

Correct Answer is C

Explanation

A client is experiencing angina and has just taken one sublingual nitroglycerin tablet. After 5 minutes, the client still reports chest pain. What should the nurse include in their teaching about the next steps? Select all that apply.

Correct Answer is ["B","E"]

Explanation

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A nurse is assessing a client presenting with sudden onset confusion and weakness in the emergency department.

For each planned action, indicate whether it is anticipated or contraindicated in the client’s care.