Patient Data

Exhibits

The nurse performs an initial rapid assessment of the client and observes facial drooping and garbled speech.

Drag one condition and one client finding to complete the sentence(s). Based on the collected data, the nurse recognizes that the client is most likely exhibiting signs of
dropdown
as evidenced by
dropdown
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}

Rationale for Correct Choices:

Stroke: The combination of facial droop, garbled speech, and sudden onset of symptoms in an older adult is strongly indicative of a stroke. The extremely elevated blood pressure supports this diagnosis as hypertension is a major risk factor and often occurs during acute cerebrovascular events.
Garbled speech: Sudden difficulty in articulating words is a common symptom of both ischemic and hemorrhagic strokes. It reflects disruption of brain areas responsible for language, making this a key diagnostic indicator of a neurologic emergency.

Rationale for Incorrect Choices:

Malignant hypertension: While the blood pressure is dangerously high, malignant hypertension typically presents with signs of end-organ damage like chest pain, vision changes, or renal impairment. It is not primarily defined by focal neurological signs like facial droop or speech issues.
Intoxication: Although alcohol can cause slurred speech, it does not explain the presence of facial asymmetry. Stroke must be prioritized in differential diagnosis when focal deficits are present, regardless of alcohol intake.
Allergic reaction: Facial droop and garbled speech are not typical of an allergic reaction, which more commonly presents with symptoms such as urticaria, airway swelling, or hypotension.
Neurological deficits: This term is accurate but too broad. Specific symptoms such as “garbled speech” provide clearer clinical evidence of stroke and should be used over general terms.
Report of alcohol consumption: While relevant to the history, this is not a clinical finding that explains the observed neurological signs. It may distract from recognizing a true medical emergency like stroke.
Vital signs: Although the blood pressure is elevated, vital signs alone are not sufficient evidence for stroke. Neurological symptoms are more specific and diagnostic.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["A","C","E"]

Explanation

Rationale:

A. Shaking that changes the child's handwriting legibility: Sudden onset of tremors affecting fine motor skills may indicate a neurological issue, such as a seizure disorder or early signs of a neurological condition, and requires prompt evaluation by the school nurse.

B. Bruises on both knees after the weekend: Bruises on the knees in children are often consistent with normal play and activity. Unless the bruises are unusual in pattern or location (e.g., upper arms, back), they typically do not require immediate referral.

C. Sunburn with blisters on the face, arms, and hands: Blistering sunburns can lead to dehydration, pain, and secondary infection. Facial involvement and blistering elevate the severity and warrant assessment and possible treatment recommendations.

D. Refuses to complete written homework assignments: While this behavior might suggest learning or behavioral challenges, it is not an urgent health issue requiring immediate referral. Teachers should monitor and possibly refer through academic support services, not directly to the nurse.

E. Thirst and frequent requests for bathroom breaks: These symptoms could be early signs of undiagnosed diabetes mellitus and warrant immediate attention from the school nurse to initiate further assessment and notify the child’s guardian.

A. Platelet count. B. Neutrophil count. C. Serum sodium level. D. Hematocrit.

Correct Answer is B

Explanation

Rationale:
A. Platelet count: Platelets are primarily responsible for clotting, not infection response. While important for monitoring bleeding risk, they do not provide relevant information about infection or inflammation.

B. Neutrophil count: Neutrophils are the primary white blood cells involved in fighting bacterial infections. An elevated neutrophil count (neutrophilia) supports the presence of infection, making this value essential to report alongside purulent drainage.

C. Serum sodium level: Sodium levels reflect fluid and electrolyte balance but are not directly related to signs of infection or wound complications. This value is not the immediate priority in the context of purulent drainage.

D. Hematocrit: Hematocrit indicates the proportion of red blood cells and is useful in evaluating anemia or fluid status, but it does not provide insight into infection or wound healing.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The school nurse is preparing a presentation for elementary school teachers to inform them when a child should be referred to the school clinic for further follow-up. The teachers should be instructed to report which situations to the school nurse? Select all that apply.

Correct Answer is ["A","C","E"]

Explanation

While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Correct Answer is B

Explanation

A client who has been taking colchicine calls the clinic with reports of an acute gout attack of the right great toe. The client has a history of kidney stones and esophageal reflux. Which finding warrants immediate intervention by the nurse?

The nurse is assigned to care for a client diagnosed with psoriasis. Which behavior by the nurse addresses this client's psychosocial need for acceptance?

Prior to obtaining a trapeze bar for a client with limited mobility, which client assessment is most important for the nurse to obtain?

The nurse is caring for a client with elevated parathyroid hormone levels. Which safety precaution should the nurse include in the plan of care?

Exhibits Nurse reviews updated chart data. For each intervention, click to indicate if it is indicated or contraindicated. Each row must have only one response option selected.

Patient Data Exhibits The client continues to have stable neurologic assessments. The nurse provides interventions to promote client safety while in the hospital. Click to indicate which interventions promote client safety. Each column must have at least one response selected.

Exhibits After two days of intensive care, the client is transferred to the telemetry floor. The floor nurse is preparing a plan of care for the client. Which modifiable risk factor(s) should the nurse include in the teaching for this client? Select all that apply.