The nurse is caring for a client who reports a sudden, severe facial numbness. The nurse observes an uneven smile with facial droop to the right side and a hand grasp strength that is weaker on the right than the left.

The client denies a recent history of headaches or trauma.

Which intervention should the nurse perform immediately?

Maintain elevated positioning of the dependent joints on the affected side.

Verify prescribed laboratory tests include prothrombin time and platelet count.

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

Administer aspirin to prevent further clot formation and platelet clumping.

Answer and Explanation

The Correct Answer is C

Choice A rationale
While maintaining elevated positioning of the dependent joints on the affected side can be helpful in certain conditions such as edema or injury, it is not the immediate intervention needed for a client presenting with sudden, severe facial numbness, uneven smile with facial droop to the right side, and a hand grasp strength that is weaker on the right than the left.
Choice B rationale
Verifying prescribed laboratory tests including prothrombin time and platelet count is important in assessing the client’s coagulation status. However, it is not the immediate intervention needed in this situation.
Choice C rationale
The client’s symptoms are suggestive of a stroke. In such cases, immediate medical intervention is crucial. Starting two large-bore IV catheters and reviewing inclusion criteria for IV fibrinolytic therapy is an appropriate immediate intervention.
Choice D rationale
Administering aspirin can be beneficial in preventing further clot formation and platelet clumping in clients at risk of a stroke. However, it is not the immediate intervention needed in this situation.

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Correct Answer is C

Explanation

C. Double vision.Double vision, or diplopia, can indicatephenytoin toxicity, which is a serious condition that may lead to impaired vision and increased risk of falls or injuries. This side effect suggests that the patient may be experiencing adverse reactions to the medication, necessitating prompt evaluation and intervention, such as checking serum phenytoin levels and possibly adjusting the medication regimen

.The other options do not require immediate intervention:

A. Chronic insomniais not a critical side effect of phenytoin and may be managed with lifestyle modifications or further assessment.
B. Puffy, bleeding gumsare common side effects associated with phenytoin (gingival hyperplasia) but are not immediately life-threatening.
D. Blood pressure 100/78 mm Hgis within normal limits and does not indicate a need for urgent action

A. Cold and dry skin. B. Facial puffiness and periorbital edema. C. Hematocrit of 30% (0.30 volume fraction). D. Further decline in the level of consciousness.

Correct Answer is D

Explanation

Choice A rationale
Cold and dry skin can be a symptom of hypothyroidism, but it’s not typically a sign that requires immediate action.
Choice B rationale
Facial puffiness and periorbital edema can be symptoms of hypothyroidism, but they’re not typically signs that require immediate action.
Choice C rationale
A hematocrit of 30% (0.30 volume fraction) is lower than the normal range, indicating anemia. While this is a concern and should be addressed, it’s not typically a sign that requires immediate action in the context of hypothyroidism.
Choice D rationale
A further decline in the level of consciousness can be a serious sign of deteriorating health in a client with hypothyroidism and should be acted upon immediately.

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Naxlex Comprehensive Predictor Exams

A client with a seizure disorder is seen at the clinic for a follow-up visit and a prescription renewal for phenytoin. Which assessment finding warrants immediate intervention by the nurse?

Correct Answer is C

Explanation

A client with a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional finding should the nurse act upon immediately?

Correct Answer is D

Explanation

Which group of foods should the nurse recommend for patients with a strong family history of colon and rectal cancers?

A nurse is educating a patient with Type 2 diabetes mellitus and peripheral neuropathy. What advice should the nurse give?

Which action should the nurse implement to reduce the risk of vesicant extravasation in the client who is receiving intravenous chemotherapy?

The nurse is educating a client, who was admitted with a blood glucose level of 580 mg/dL, on how to prevent complications related to diabetes mellitus. Which statement made by the client indicates they have understood the information?

Which group of foods is best for the nurse to recommend for clients with a strong family history of colon and rectal cancers?

A client is diagnosed with chronic kidney disease and needs to begin dialysis. Which condition entered on the client’s medical record should the nurse recognize as a contraindication for peritoneal dialysis?