A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first?

Complete blood count (CBC)

Electroencephalogram (EEG)

Computed tomography (CT) scan

Chest radiograph (chest x-ray)

Answer and Explanation

The Correct Answer is C

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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Correct Answer is ["8"]

Explanation

Given:

Total volume to infuse: 150 mL

Infusion time: 3 hours

Drop factor of tubing: 10 gtt/mL

To find:

Drip rate (gtt/min)

Step 1: Convert infusion time to minutes

3 hours x 60 minutes/hour = 180 minutes

Step 2: Calculate the total number of drops

Total drops = Total volume x Drop factor

Total drops = 150 mL x 10 gtt/mL = 1500 gtt

Step 3: Calculate the drip rate

Drip rate = Total drops / Infusion time in minutes

Drip rate = 1500 gtt / 180 minutes = 8.33 gtt/min

Step 4: Round to the nearest whole number

Since the question asks for the drip rate rounded to the nearest whole number, we round 8.33 to 8 gtt/min.

A. Have the client use the call light if they need to get up B. Pad the side rails of the client’s bed C. Ensure the lights in the room are as bright as possible at all times D. Avoid over stimulation and excessive activity in the client’s room

Correct Answer is C

Explanation

A. "Have the client use the call light if they need to get up":
This is an appropriate precaution to promote safety for a patient who has seizures. It is important to encourage patients to call for assistance before getting up, especially if they are at risk for seizures. Having the patient use the call light ensures that they do not try to walk or move without supervision, which could lead to falls or injury.

B. "Pad the side rails of the client’s bed":
This is also an appropriate precaution. Padding the side rails of the bed is a common safety measure for patients who are at risk for seizures. The padding helps prevent injury if the patient moves during a seizure. Side rails should be raised during a seizure to prevent the patient from falling out of bed, but the risk of injury from the side rails themselves is minimized with padding.

C. "Ensure the lights in the room are as bright as possible at all times":
This is not an appropriate precaution. Bright lights in the room could potentially cause overstimulation, which may be a trigger for seizures in some patients. In addition, bright lights could contribute to discomfort and anxiety. Instead, the room should be kept at a comfortable, calm lighting level to help reduce stress and minimize the risk of triggering a seizure.

D. "Avoid over stimulation and excessive activity in the client’s room":
This is an appropriate precaution. Avoiding overstimulation is important for patients with seizure disorders. Excessive noise, bright lights, or other sources of stress or agitation could provoke a seizure. A calm, quiet environment helps to promote safety and reduce the risk of a seizure occurring.

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A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["8"]

Explanation

The nurse is caring for a patient who was admitted for seizures. All of the following precautions should be taken to promote a safe environment except which?

Correct Answer is C

Explanation

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