A nurse is assessing a client who has sickle cell anemia. Which of the following findings is the priority for the nurse to report?

Slurred speech

Yellowed sclera

Ulcers on the ankles

Swelling in the joints

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Slurred speech could indicate a potential neurological complication in a client with sickle cell anemia, such as a stroke. Neurological symptoms require immediate attention and reporting to the healthcare provider.

Choice B rationale:

Yellowed sclera (jaundice) can be related to sickle cell anemia but is less acutely concerning than slurred speech.

Choice C rationale:

Ulcers on the ankles are often associated with sickle cell anemia, but they are not as urgent as neurological symptoms.

Choice D rationale:

Swelling in the joints is a potential manifestation of sickle cell anemia, but slurred speech indicates a more acute and concerning issue.

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Correct Answer is A

Explanation

Choice A rationale:

The client is experiencing signs of an allergic reaction or anaphylaxis, which can be life-threatening. The rapid response team should be called to provide immediate medical assistance.

Choice B rationale:

Intubation is not the immediate priority. Addressing the allergic reaction and ensuring the client's airway, breathing, and circulation are the first steps.

Choice C rationale:

Obtaining an arterial blood gas (ABG) level is not the priority when the client is experiencing respiratory distress and facial swelling.

Choice D rationale:

Administering diphenhydramine may be part of the treatment plan, but the immediate priority is to call for emergency assistance to manage the allergic reaction.

A. Aphasia B. Depression C. Loss of depth perception D. Slow, cautious behavior

Correct Answer is C

Explanation

Choice A rationale:

Aphasia, or difficulty with language, is more commonly associated with left hemispheric stroke.

Choice B rationale:

Depression can be a common psychological reaction following stroke, but it is not a specific finding associated with right hemispheric stroke.

Choice C rationale:

Right hemispheric stroke can lead to loss of depth perception and spatial awareness due to its impact on the visual-spatial processing areas of the brain.

Choice D rationale:

Slow, cautious behavior is a common finding after stroke regardless of the affected hemisphere.

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A nurse is assessing a client who has sickle cell anemia. Which of the following findings is the priority for the nurse to report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving an initial dose of vancomycin IV. The client begins experiencing dyspnea and swelling of the face. After discontinuing the vancomycin infusion, which of the following actions should the nurse take next?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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