The nurse is caring for a client with a suspected stroke. Which intervention should the nurse prioritize?

Administer aspirin as prescribed

Obtain a head CT scan

Monitor blood glucose levels

Elevate the head of the bed

Answer and Explanation

The Correct Answer is B

Choice A reason: Administering aspirin is appropriate for ischemic stroke but premature without confirming stroke type. Hemorrhagic stroke contraindicates aspirin. A head CT scan distinguishes ischemic from hemorrhagic stroke, guiding treatment, making it the priority to ensure safe intervention.

Choice B reason: Obtaining a head CT scan is the priority, as it differentiates ischemic from hemorrhagic stroke, critical for guiding treatment like thrombolytics or anticoagulation. Rapid imaging within the therapeutic window ensures timely intervention, minimizing brain damage, making it the essential first step.

Choice C reason: Monitoring blood glucose is important, as hyperglycemia worsens stroke outcomes, but it is secondary to confirming stroke type. A head CT scan provides diagnostic clarity, guiding urgent therapy, making imaging the priority over metabolic assessments in suspected stroke.

Choice D reason: Elevating the head of the bed reduces intracranial pressure but is not the first step. A head CT scan confirms stroke type, ensuring appropriate interventions like thrombolytics for ischemic stroke, making imaging critical to guide management and prevent further brain injury.

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Correct Answer is C

Explanation

Choice A reason: Chest x-ray may show nonspecific findings in pulmonary embolism but is not diagnostic. D-dimer, a fibrin degradation product, is highly sensitive for detecting thrombosis, guiding further imaging like CT pulmonary angiography, making it the priority test in suspected cases.

Choice B reason: Electrocardiogram may show tachycardia or right heart strain in pulmonary embolism but is nonspecific. D-dimer is a sensitive screening test, indicating clot presence, which prompts definitive imaging, making it the preferred initial diagnostic step in suspected pulmonary embolism.

Choice C reason: D-dimer blood test is the most sensitive screening tool for pulmonary embolism, detecting fibrin degradation from clots. Elevated levels prompt CT pulmonary angiography for confirmation, guiding urgent treatment to prevent further embolization, making it the critical test to anticipate.

Choice D reason: Arterial blood gas may reveal hypoxemia in pulmonary embolism but is nonspecific, as other conditions cause similar findings. D-dimer is more diagnostic, identifying clot presence, guiding imaging, and ensuring timely intervention, making it the priority test in suspected cases.

A. Reports of chronic constipation and serum gastrin levels B. Serum Helicobacter pylori antibody results and urine output amounts C. Presence of bowel sounds and degree of abdominal pain D. Severity of nausea and vomiting and serum amylase results

Correct Answer is D

Explanation

Choice A reason: Chronic constipation and serum gastrin levels are not directly relevant to acute pancreatitis. Constipation may indicate gastrointestinal issues, but gastrin primarily relates to gastric acid secretion. These do not confirm pancreatitis or guide acute management, unlike amylase levels, which are diagnostic for pancreatic inflammation.

Choice B reason: Helicobacter pylori antibodies indicate gastric infection, unrelated to pancreatitis, which involves pancreatic inflammation. Urine output is a general vital sign but not specific to pancreatitis diagnosis. Amylase and symptom severity are more critical for confirming and managing acute pancreatitis, making this less valuable.

Choice C reason: Bowel sounds and abdominal pain degree provide general information but are nonspecific. Pain is expected in pancreatitis, and bowel sounds may vary. Serum amylase and nausea/vomiting severity are more diagnostic, directly reflecting pancreatic inflammation and its systemic effects, making them more critical to report.

Choice D reason: Serum amylase levels are a key diagnostic marker for acute pancreatitis, as pancreatic inflammation releases amylase into the blood. Severity of nausea and vomiting reflects disease impact and fluid loss, guiding treatment. These are the most valuable data for reporting, as they confirm diagnosis and inform management.

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The nurse is caring for a client with a suspected stroke. Which intervention should the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with a suspected pulmonary embolism. Which diagnostic test should the nurse anticipate?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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