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Patient Data

Exhibits

The triage nurse does a rapid assessment of the client.

Click to highlight the data that indicates the client is in need of immediate health interventions.

A 70-year-old female presents to the emergency department (ED) through triage with a noticeable facial droop and garbled speech. After having a few drinks at a local seafood restaurant, the client's husband noticed his wife's speech became difficult to understand.

noticeable facial droop

garbled speech

few drinks at a local seafood restaurant

speech became difficult to understand.

Answer and Explanation

The Correct Answer is ["A","B","D"]

Rationale for correct Choices:

Noticeable facial droop: Facial drooping is a hallmark sign of a stroke. Early recognition is critical because prompt intervention, such as thrombolytic therapy, must occur within a narrow time window to prevent long-term neurological damage.
Garbled speech: Slurred or incomprehensible speech (dysarthria or aphasia) is another acute stroke symptom. It indicates potential involvement of the brain's language centers and requires immediate neuroimaging and evaluation.
Speech became difficult to understand: A sudden change in speech pattern strongly suggests an evolving neurologic event such as a transient ischemic attack (TIA) or stroke. Timely identification of symptom onset is essential for determining eligibility for time-sensitive stroke treatments like alteplase.

Rationale for Incorrect Choices:

Few drinks at a local seafood restaurant: While alcohol can cause slurred speech and sea food can result in allergic reaction, the patient reports with symptoms suggestive of a stroke, therefore this is not part of the immediate concerns.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:

A. Confirm that the desired effect of the medication has been achieved: Trazodone is prescribed to improve mood and aid sleep, not to enhance cognitive function. Since the caregiver reports improvement in those areas, the medication is achieving its intended therapeutic outcomes.

B. Explain that it may take several weeks for the medication to be effective: While some antidepressants require time to reach full effectiveness, the caregiver already reports improved mood and sleep. There is no indication of delayed onset.

C. Evaluate when and how the medication is being administered to the client: No signs of improper administration or ineffective dosing are indicated. The caregiver's feedback suggests the medication is being given correctly and is having a beneficial effect.

D. Notify the healthcare provider that a change in dosage may be needed: Cognitive decline in Alzheimer's disease is progressive and not expected to improve with trazodone, so no dosage change is warranted based on this feedback.

A. Place client on 2 L/minute oxygen. B. Start 0.9% sodium chloride fluid bolus C. Ensure surgical consent has been completed. D. Insert indwelling urinary catheter. E. Document any skin lesions on lower legs. F. Mark pedal pulse sites with a single use marker.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

Rationale:

Place client on 2 L/minute oxygen: The client's oxygen saturation is borderline at 94%, and with suspected aortic aneurysm and possible compromise, low-flow oxygen can help ensure adequate tissue oxygenation. This intervention is safe and aligns with the standing PRN order.
Start 0.9% sodium chloride fluid bolus: Given the client’s low-normal blood pressure and risk for aneurysm rupture, fluid resuscitation may be needed to support perfusion. Carefully titrated fluids are appropriate to maintain hemodynamic stability while awaiting definitive surgical management.
Ensure surgical consent has been completed: Time is critical in suspected abdominal aortic aneurysm (AAA) rupture. Preoperative preparation, including confirming surgical consent, should be done early in anticipation of emergent vascular intervention.
Insert indwelling urinary catheter: This is contraindicated until the aneurysm is surgically managed or ruled out. Inserting a catheter increases intra-abdominal pressure and may worsen an unstable aneurysm. Additionally, unnecessary movement may elevate the risk of rupture in a fragile vessel.
Document any skin lesions on lower legs: Peripheral vascular disease is often comorbid with aneurysms. Noting skin lesions helps establish a vascular baseline and may inform intraoperative risk or postoperative wound healing considerations.
Mark pedal pulse sites with a single use marker: Pulse marking is essential preoperatively in vascular cases to monitor distal perfusion post-surgery. Marking now ensures pulses can be quickly located after potential surgical repair of the aneurysm.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

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.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

The first paddle has been placed on the chest of a client who needs defibrillation. Where should the nurse place the second paddle? (Mark the location where the second paddle should be placed on the image)

The nurse is planning an educational session for new parents on ways to prevent sudden infant death syndrome (SIDS). Which information is most important to provide parents of newborns and infants?

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

A client received a thrombolytic medication following a myocardial infarction. When the client has a bowel movement, which action should the nurse implement?

A client is receiving IV fluids by gravity infusion and exhibits signs of fluid volume overload. When assessing the client's IV delivery system, where should the nurse assess first?

When entering the room of a sedated postoperative client, which assessment requires immediate intervention by the nurse?

A client with fibromyalgia asks the nurse to arrange for hospice care to help manage the severe, chronic pain. Which intervention should the nurse provide to address the client's problem?