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 B

Explanation

Choice A reason: Delegating oral care to UAP is appropriate for routine hygiene in AIDS patients with candidiasis. Leaving oral care solely to the nurse is unnecessary unless complex treatments are required. A soft-bristled toothbrush ensures safe, effective cleaning, supporting UAP involvement in standard oral hygiene.

Choice B reason: A soft-bristled toothbrush is ideal for oral care in candidiasis, as it gently cleans without traumatizing painful ulcers. In AIDS, oral hygiene reduces fungal load and discomfort. This instruction ensures safe, effective care by UAP, aligning with standard hygiene practices for mucosal infections.

Choice C reason: Sterile gloves are unnecessary for routine oral care, as candidiasis is not highly contagious in this context. Standard precautions, including clean gloves, suffice for UAP performing hygiene. Requiring sterile gloves is excessive, complicating care without added benefit compared to using a soft toothbrush.

Choice D reason: Mouthwash may irritate candidiasis ulcers, especially if alcohol-based, and is not the priority. Brushing with a soft-bristled toothbrush effectively cleans the mouth without causing trauma. Mouthwash is secondary and requires nurse oversight to ensure compatibility with the client’s condition, unlike brushing.

A. Rebound tenderness in the right lower quadrant B. Diffuse abdominal pain C. Decreased bowel sounds D. Elevated blood pressure

Correct Answer is A

Explanation

Choice A reason: Rebound tenderness in the right lower quadrant (McBurney’s point) is a hallmark of appendicitis, indicating peritoneal irritation from an inflamed appendix. This localized pain, elicited on palpation release, is highly specific, guiding urgent surgical evaluation to prevent rupture and peritonitis.

Choice B reason: Diffuse abdominal pain is nonspecific and occurs in various conditions, not uniquely appendicitis, which typically presents with localized right lower quadrant pain. Rebound tenderness is more diagnostic, as it directly reflects appendiceal inflammation, making it the priority finding.

Choice C reason: Decreased bowel sounds may occur in appendicitis due to ileus but are nonspecific, seen in other abdominal conditions. Rebound tenderness is more indicative, as it localizes to the appendix, confirming peritoneal irritation, critical for diagnosing acute appendicitis.

Choice D reason: Elevated blood pressure is not specific to appendicitis and may reflect pain or stress. Rebound tenderness directly indicates appendiceal inflammation, making it the most reliable finding, as it guides diagnosis and urgent intervention to prevent complications like perforation.

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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

An adult client is admitted with AIDS and oral candidiasis manifested by several painful mouth ulcers. The nurse delegates oral care to the unlicensed assistive personnel (UAP) and discusses how to assist the client. Which instruction should the nurse provide the UAP?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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