The nurse is caring for a client who arrives to the emergency department with reports of experiencing dizziness and difficulty walking to the bathroom.
The nurse observes right-sided weakness and sluggish enunciation of speech. The nurse should immediately take which action?

Keep the bed in the lowest position and initiate seizure and fall precautions.

Place an indwelling urinary catheter and measure strict intake and output.

Maintain elevated positioning of the dependent joints on affected side.

Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.

Answer and Explanation

The Correct Answer is D

Choice A reason: Keeping the bed in the lowest position and initiating seizure and fall precautions is not an immediate action for the nurse to take. Seizure and fall precautions are measures that prevent injury or harm to the client in case of a seizure or a fall. Seizure and fall precautions include lowering the bed, padding the side rails, removing any objects that may cause injury, and having suction and oxygen equipment ready. However, these precautions are not specific to the client's condition and do not address the underlying cause.

Choice B reason: Placing an indwelling urinary catheter and measuring strict intake and output is not an urgent action for the nurse to take. An indwelling urinary catheter is a tube that drains urine from the bladder into a collection bag. Measuring intake and output is a way of monitoring fluid balance and kidney function. However, these interventions are not essential for the client's condition and may increase the risk of infection or trauma.

Choice C reason: Maintaining elevated positioning of the dependent joints on affected side is not a relevant action for the nurse to take. Dependent joints are joints that are below the level of the heart, such as the ankles or wrists. Elevating dependent joints can help reduce swelling or pain by improving blood flow and drainage. However, this intervention is not related to the client's condition and does not improve neurological function.

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

Explanation

Choice A reason: Consuming foods with saturated fats can increase the level of low-density lipoprotein (LDL) cholesterol in the blood, which can contribute to plaque formation and narrowing of the coronary arteries.

Choice B reason: Walking 30 minutes per day can help lower blood pressure, improve blood circulation, and reduce the risk of heart attack and stroke.

Choice C reason: Using a salt substitute can help lower sodium intake, which can reduce fluid retention and lower blood pressure.

Choice D reason: Keeping a food diary can help the client monitor their calorie intake, portion size, and nutritional balance.

Choice E reason: Eating more canned vegetables can increase sodium intake, which can worsen fluid retention and blood pressure. Fresh or frozen vegetables are preferable.

Choice F reason: Including oatmeal for breakfast can provide soluble fiber, which can lower LDL cholesterol and prevent plaque formation in the coronary arteries.

A. Instruct the client to increase his intake of oral fluids until the skin flushing is relieved. B. Advise the client to place one nitroglycerin tablet under his tongue as a precaution. C. Tell the client to have someone bring him to an emergency department immediately. D. Reassure the client that facial flushing is a common side effect of the medication.

Correct Answer is D

Explanation

Choice A: Increasing oral fluids may help with hydration, but it will not reduce skin flushing caused by lisinopril. Lisinopril is an angiotensin-converting enzyme (ACE. inhibitor that dilates blood vessels and lowers blood pressure. Flushing occurs due to increased blood flow to the skin.

Choice B: Nitroglycerin is a vasodilator that relaxes smooth muscle in blood vessels and reduces chest pain caused by angina. It is not indicated for skin flushing caused by lisinopril. Moreover, nitroglycerin can lower blood pressure further and cause hypotension, headache, dizziness, and fainting.

Choice C: Going to an emergency department is not necessary for skin flushing caused by lisinopril. Flushing is not a sign of an allergic reaction or anaphylaxis, which would require immediate medical attention. Flushing is also not a symptom of a heart attack or stroke, which would present with other signs such as chest pain, shortness of breath, arm numbness, or slurred speech.

Choice D: Reassuring the client that facial flushing is a common side effect of lisinopril is the best action for the nurse to take. Flushing is not harmful or dangerous, and it usually subsides within a few hours. The nurse should explain the mechanism of action of lisinopril and its benefits for lowering blood pressure and preventing angina. The nurse should also advise the client to monitor his blood pressure regularly and report any signs of hypotension, such as dizziness, lightheadedness, or fainting.

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The nurse is caring for a client who arrives to the emergency department with reports of experiencing dizziness and difficulty walking to the bathroom.The nurse observes right-sided weakness and sluggish enunciation of speech. The nurse should immediately take which action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Text 1:The nurse is providing lifestyle change education for a client to slow the progression of coronary artery disease. Which statement(s) made by the client should the nurse recognize as needing additional education? (Select all that apply.)

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

Explanation

A male client reports to the on-call clinic nurse that he took two tablets of 10 mg lisinopril by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina, but denies experiencing any chest pain at the moment or recently. Which action should the nurse take?

Correct Answer is D

Explanation

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The nurse is caring for a client who arrives to the emergency department with reports of experiencing dizziness and difficulty walking to the bathroom.
The nurse observes right-sided weakness and sluggish enunciation of speech. The nurse should immediately take which action?