The nurse assists with care of a confused patient who presents to the emergency department with stroke symptoms. Vital signs are blood pressure 174/100 mm Hg. pulse 64 beats per minute, and SpO2 88% on room air. Which nursing intervention is priority?

Obtain an electrocardiogram (ECG) exam

Obtain intravenous access

Administer 2 L of oxygen per nasal cannula

Obtain a rectal temperature

Answer and Explanation

The Correct Answer is C

A. Obtain an electrocardiogram (ECG) exam: While an ECG is important to assess cardiac status, it is not the immediate priority compared to addressing the low oxygen saturation.
B. Obtain intravenous access: IV access is important for administering medications and fluids but does not take precedence over addressing hypoxia.
C. Administer 2 L of oxygen per nasal cannula: This is correct. The priority is to improve oxygenation since hypoxia can exacerbate neurological damage in a stroke patient. An SpO2 of 88% is low and requires immediate correction to prevent further complications.
D. Obtain a rectal temperature: Temperature assessment is not as urgent as addressing the immediate need for oxygen to improve SpO2 levels.

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Correct Answer is B

Explanation

A. Impaired Physical Mobility: This is not directly related to hypertension management. While hypertension can affect physical activity, it is not the primary focus in the context of managing high blood pressure.
B. Readiness for Enhanced Health Literacy: This is the correct focus. Educating the patient about hypertension management, lifestyle modifications, and medication adherence is crucial in managing and controlling blood pressure.
C. Decreased Activity Tolerance: This could be a related issue but is not the primary focus. It addresses the impact of hypertension on physical capacity rather than managing the condition itself.
D. Ineffective Airway Clearance: This is unrelated to hypertension. It focuses on respiratory issues rather than blood pressure management.

A. "You should increase your daily exercise." B. "Eat a low-sodium and low-potassium diet." C. "Oral contraceptives have no effect on stroke risk." D. "Strict blood glucose control is important E. "Excessive alcohol intake can increase your risk."

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

Explanation

A. "You should increase your daily exercise.": Regular physical activity helps lower blood pressure, improve cardiovascular health, and reduce the risk of stroke.
B. "Eat a low-sodium and low-potassium diet.": While reducing sodium intake is beneficial, potassium is actually important for blood pressure regulation. A diet rich in potassium is often recommended to help manage blood pressure.
C. "Oral contraceptives have no effect on stroke risk.": This statement is incorrect. Some oral contraceptives, especially those with higher estrogen content, can increase the risk of stroke, particularly in women with other risk factors.
D. "Strict blood glucose control is important.": Proper management of blood glucose levels is crucial for preventing stroke, especially in individuals with diabetes, as poorly controlled diabetes can lead to vascular complications.
E. "Excessive alcohol intake can increase your risk.": Excessive alcohol consumption is a known risk factor for hypertension and stroke. Moderation is key to reducing stroke risk.

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The nurse assists with care of a confused patient who presents to the emergency department with stroke symptoms. Vital signs are blood pressure 174/100 mm Hg. pulse 64 beats per minute, and SpO2 88% on room air. Which nursing intervention is priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse contributes to the plan of care for a patient with hypertension. Which of the following nursing diagnoses is the focus of care for the patient with hypertension?

Correct Answer is B

Explanation

A patient asks the nurse how to prevent a stroke. Which statement by the nurse is correct? Select all that apply.

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

Explanation

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