During a preoperative assessment phone call, a client reports taking several “pills” every day. Which response should the office nurse provide?

Discuss with your healthcare provider which medications to take before surgery

Bring copies of all your prescription records

Bring all of your medication containers to your preoperative appointment

Obtain a copy of your medication records from your healthcare provider (HCP)

Answer and Explanation

The Correct Answer is C

Choice A reason: Discussing medications with the provider is necessary but vague and not actionable during the call. Bringing medication containers provides concrete data, ensuring accurate preoperative reconciliation, reducing risks like drug interactions, making this response less effective for immediate medication assessment.

Choice B reason: Bringing prescription records is helpful but less direct than medication containers, which show current drugs, doses, and adherence. Records may be incomplete, and containers allow visual verification, ensuring accurate perioperative planning, making this response secondary to physical medication review.

Choice C reason: Bringing medication containers is the best response, as it allows the nurse to verify all current medications, doses, and schedules. This ensures accurate preoperative reconciliation, preventing drug interactions or withdrawal, critical for safe anesthesia and surgery, making it the priority instruction.

Choice D reason: Obtaining records from the provider is time-consuming and may delay preoperative planning. Medication containers provide immediate, accurate data for reconciliation, reducing risks of errors, making this response less practical than having the client bring physical containers for direct review.

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Correct Answer is C

Explanation

Choice A reason: Profuse diaphoresis and headache are non-specific and not part of Cushing’s triad (bradycardia, irregular respirations, widened pulse pressure). Increased ICP causes specific cardiovascular and respiratory changes, and these symptoms are more aligned with autonomic dysfunction, making this finding incorrect for Cushing’s triad.

Choice B reason: Chest pain and shortness of breath suggest cardiopulmonary issues, not Cushing’s triad, which reflects increased ICP via bradycardia, irregular breathing, and widened pulse pressure. These symptoms are unrelated to intracranial dynamics, making this finding irrelevant for the expected manifestations of ICP.

Choice C reason: Hypotension is incorrect; Cushing’s triad includes hypertension, not hypotension, with bradycardia and irregular respirations due to ICP compressing brainstem centers. Venous pooling is unrelated, and this choice misrepresents the triad, but it is listed as the answer in error, as hypertension is expected.

Choice D reason: Painful urination and hematuria indicate urinary tract issues, not increased ICP or Cushing’s triad. The triad involves neurological and cardiovascular signs (hypertension, bradycardia, irregular breathing), and urinary symptoms are irrelevant, making this finding incorrect for ICP-related manifestations.

A. Palpable cervical lymph node B. Carotid bruit C. Nuchal rigidity D. Jugular vein distention

Correct Answer is B

Explanation

Choice A reason: Palpable cervical lymph nodes suggest infection or malignancy, not stroke risk. Stroke is linked to vascular issues like carotid stenosis, detected by bruit. Lymph nodes are unrelated to cerebrovascular pathology, making this finding irrelevant for identifying stroke risk in the client.

Choice B reason: Carotid bruit indicates turbulent flow from stenosis, a major stroke risk due to potential embolism or reduced cerebral perfusion. This vascular finding directly correlates with ischemic stroke, making it the most critical assessment to report for stroke prevention and evaluation.

Choice C reason: Nuchal rigidity suggests meningitis or subarachnoid hemorrhage, not ischemic stroke risk. Carotid bruit is a specific precursor to embolic stroke, and nuchal rigidity addresses different neurological conditions, making this finding less relevant for stroke risk assessment.

Choice D reason: Jugular vein distention indicates heart failure or venous pressure, not arterial stroke risk. Carotid bruit directly relates to cerebrovascular disease, a stroke precursor, making jugular distention irrelevant, as it reflects cardiovascular, not cerebrovascular, pathology in stroke risk evaluation.

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During a preoperative assessment phone call, a client reports taking several “pills” every day. Which response should the office nurse provide?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with suspected increased intracranial pressure (ICP) exhibits clinical manifestations of Cushing’s triad. Which assessment finding would the nurse expect to observe?

Correct Answer is C

Explanation

The nurse reports that a client is at risk for a stroke based on which assessment finding?

Correct Answer is B

Explanation

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