The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse?
The patient has difficulty speaking.
There are fine crackles at the lung bases.
The pulse rate is 102 beats/min.
The blood pressure is 144/86 mm Hg.
The Correct Answer is A
Choice A reason: Difficulty speaking post-carotid artery angioplasty suggests a neurological complication, possibly stroke, requiring immediate intervention. This aligns with post-procedure neurological assessment priorities, making it the most concerning finding for the nurse to address urgently in the patient’s care.
Choice B reason: Fine crackles at lung bases may indicate fluid overload but are less urgent than speech difficulty, which suggests stroke. Neurological complications take precedence, making this secondary and incorrect compared to the nurse’s priority of addressing potential cerebral events post-procedure.
Choice C reason: A pulse of 102 beats/min is mildly elevated but less critical than speech difficulty, which may indicate a neurological event. Stroke risk is the primary concern, making this less urgent and incorrect compared to the nurse’s focus on neurological assessment post-angioplasty.
Choice D reason: Blood pressure of 144/86 mm Hg is elevated but within acceptable post-procedure ranges. Speech difficulty suggests a neurological issue, making this less concerning and incorrect compared to the nurse’s priority of evaluating potential stroke in the patient post-angioplasty.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Four-point restraints increase agitation and risk injury in delirious patients, worsening confusion. Family presence calms and reorients, making this harmful and incorrect compared to the nurse’s goal of creating a safe, calming environment for the patient with delirium.
Choice B reason: Encouraging family members to stay provides familiarity and reassurance, reducing agitation in delirious patients. This aligns with delirium management guidelines, making it the correct intervention to create a calm and safe environment for the patient experiencing delirium in the hospital.
Choice C reason: A dark, quiet room may disorient delirious patients further, increasing confusion. Family presence offers comfort, making this counterproductive and incorrect compared to the nurse’s aim of fostering a supportive, orienting environment for the patient with delirium.
Choice D reason: High-dose sedatives risk oversedation and worsen delirium, not calming the patient safely. Family presence supports orientation, making this risky and incorrect compared to the nurse’s focus on non-pharmacological interventions to create a safe environment for the delirious patient.
Correct Answer is D
Explanation
Choice A reason: Increased serum sodium is not expected in SIADH, which causes water retention, diluting sodium. Decreased sodium is typical, making this incorrect, as it contradicts the hyponatremia associated with SIADH in the nurse’s laboratory assessment of the hospitalized patient.
Choice B reason: Serum chloride may vary but isn’t primarily affected in SIADH, where hyponatremia is key. Decreased sodium is the expected finding, making this irrelevant and incorrect compared to the nurse’s focus on sodium levels in the patient with SIADH symptoms.
Choice C reason: Increased hematocrit suggests hemoconcentration, not typical in SIADH, where fluid retention dilutes blood components. Decreased sodium is expected, making this incorrect, as it does not align with the fluid dynamics of SIADH in the nurse’s laboratory evaluation.
Choice D reason: Decreased serum sodium (hyponatremia) results from water retention in SIADH, causing dilution. This aligns with endocrine disorder lab findings, making it the correct laboratory result the nurse would expect in a patient hospitalized with SIADH, headache, and muscle cramps.
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