A patient who is diagnosed with a stroke is requesting a glass of water. Which action is appropriate for the nurse to take?

Give the patient a glass of water.

Check the patient's dysphagia screen

Consult speech pathology.

Teach that stroke patients are nothing by mouth (NPO)

Answer and Explanation

The Correct Answer is B

A. Give the patient a glass of water.: Giving the patient water without assessing their swallowing ability can be dangerous due to the risk of aspiration.
B. Check the patient's dysphagia screen.: Assessing for dysphagia is crucial because stroke patients often have impaired swallowing, which increases the risk of aspiration and choking.
C. Consult speech pathology.: Consulting a speech pathologist is important for a comprehensive swallowing assessment, but it is not the immediate action when a patient requests water.
D. Teach that stroke patients are nothing by mouth (NPO).: Not all stroke patients are NPO. This decision is based on the patient's ability to swallow safely, determined by a dysphagia screen.

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Correct Answer is D

Explanation

A. Ecchymosis: Ecchymosis (bruising) is not a typical symptom of peripheral arterial occlusive disease. It generally indicates bleeding or trauma to the skin and subcutaneous tissues.
B. Stasis ulcers: Stasis ulcers are associated with chronic venous insufficiency, not peripheral arterial disease.
C. Angina: Angina refers to chest pain due to reduced blood flow to the heart, and it is associated with coronary artery disease, not peripheral arterial occlusive disease.
D. Intermittent claudication: This is the classic symptom of peripheral arterial occlusive disease, characterized by muscle pain or cramping in the legs triggered by physical activity and relieved by rest. It is due to insufficient blood flow to the muscles during exercise.

A. Has the patient been taking his medications as prescribed? B. Does the patient hurt anywhere else? C. When does the patient take his furosemide? D. Has the patient fallen before?

Correct Answer is D

Explanation

Has the patient been taking his medications as prescribed? This is the most important information to collect. Understanding the patient's medication adherence is crucial because if the patient is not taking his medications as prescribed, it could explain why his blood pressure is elevated. Noncompliance with medication regimens is a common cause of hypertensive urgency and can lead to severe complications. Therefore, knowing whether he has been taking his medications regularly and correctly would directly influence the management plan and help identify the cause of the current crisis.

Does the patient hurt anywhere else? While it’s important to assess for pain and discomfort to address immediate symptoms, this information does not directly address the potential cause of the elevated blood pressure. The patient already reported pain in the head, chest, and left leg, so the primary concern is managing his hypertensive urgency and understanding its underlying causes rather than identifying additional pain locations at this moment.

When does the patient take his furosemide? Knowing the timing of furosemide intake could provide insights into his diuretic therapy management and its potential impact on his blood pressure. However, it is less immediately relevant than understanding whether he has been taking all his medications as prescribed. This question might be more pertinent once medication adherence is confirmed to understand diuretic effects throughout the day.

Has the patient fallen before? This is relevant for assessing the risk of recurrent falls and potential underlying issues such as orthostatic hypotension or balance problems, which are crucial for long-term management and safety. However, it is not as immediately critical in the context of the current hypertensive urgency and the elevated blood pressure despite medication.

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A patient who is diagnosed with a stroke is requesting a glass of water. Which action is appropriate for the nurse to take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Correct Answer is D

Explanation

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