The nurse is caring for the following clients. Which client would the nurse assess first after receiving shift report?
The client admitted with complaints of left-sided weakness who is scheduled for a magnetic resonance imaging (MRI) scan.
The client diagnosed with a cerebrovascular accident who has expressive aphasia.
The client diagnosed with a concussion who is complaining about being woken up every two hours.
The client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale score of 6.
The Correct Answer is D
Choice A reason: Left-sided weakness suggests a possible stroke, requiring urgent evaluation, but a scheduled MRI indicates initial assessment has occurred. The client’s condition appears stable enough for diagnostic planning, suggesting no immediate life-threatening deterioration. This is less urgent than a client with a critically low Glasgow Coma Scale score indicating severe neurological compromise.
Choice B reason: Expressive aphasia in a client with a confirmed cerebrovascular accident indicates a stable neurological deficit post-stroke. While significant, this condition is not immediately life-threatening, and ongoing monitoring is likely in place. The priority is lower than a client with acute, severe neurological impairment indicated by a critically low Glasgow Coma Scale score.
Choice C reason: A concussion patient complaining about frequent wake-ups is likely stable, as routine neurological checks are standard protocol. The complaint reflects discomfort rather than acute deterioration. This is less urgent than a client with a Glasgow Coma Scale score of 6, which indicates severe neurological compromise requiring immediate assessment.
Choice D reason: A Glasgow Coma Scale score of 6 indicates severe neurological impairment, likely from traumatic brain injury after a motorcycle accident. This score reflects critical deficits in eye-opening, verbal, and motor responses, signaling potential life-threatening conditions like brain swelling or hemorrhage. Immediate assessment is essential to prevent further deterioration or death, making this the highest priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Common side effects of disulfiram include mild nausea, headache, or fatigue, resulting from its inhibition of aldehyde dehydrogenase. However, severe nausea and vomiting are not typical unless triggered by alcohol consumption, which causes a disulfiram-alcohol reaction, making this an unlikely primary cause of the client’s distress.
Choice B reason: Disulfiram inhibits aldehyde dehydrogenase, causing acetaldehyde buildup when alcohol is consumed, leading to severe nausea, vomiting, and flushing. This disulfiram-alcohol reaction is the most likely cause of the client’s symptoms, as it is designed to deter alcohol use in substance abuse treatment, matching the described distress.
Choice C reason: An overdose of disulfiram is rare and typically causes symptoms like drowsiness or confusion, not severe nausea and vomiting. The client’s symptoms align more closely with the disulfiram-alcohol reaction, which is a pharmacological effect, not an overdose, making this an unlikely cause.
Choice D reason: An allergic response to disulfiram might cause rash, itching, or anaphylaxis, but severe nausea and vomiting are not typical allergic symptoms. These symptoms are more consistent with the disulfiram-alcohol reaction, where acetaldehyde accumulation triggers intense gastrointestinal distress, ruling out allergy as the likely cause.
Correct Answer is ["C","E"]
Explanation
Choice A reason: Borderline personality disorder is a Cluster B disorder, characterized by emotional instability and impulsivity due to dysfunctional emotional regulation circuits, including the amygdala and prefrontal cortex. It does not belong to Cluster A, which includes eccentric and odd behaviors, making it an incorrect choice for this category.
Choice B reason: Avoidant personality disorder is a Cluster C disorder, marked by anxiety and fear of rejection, linked to heightened amygdala sensitivity to social threats. Cluster A disorders involve odd or eccentric traits, not anxiety-driven avoidance, so avoidant personality disorder does not fit the Cluster A category.
Choice C reason: Schizotypal personality disorder is a Cluster A disorder, characterized by eccentric behavior, odd beliefs, and perceptual distortions, likely due to subtle brain abnormalities in the frontal and temporal lobes. These traits align with the odd, eccentric nature of Cluster A, making it a correct choice for this category.
Choice D reason: Antisocial personality disorder is a Cluster B disorder, involving impulsivity and disregard for others, associated with reduced prefrontal cortex regulation of aggressive impulses. It does not exhibit the eccentric or odd traits of Cluster A, making it an incorrect choice for this personality disorder cluster.
Choice E reason: Paranoid personality disorder is a Cluster A disorder, marked by pervasive distrust and suspiciousness, potentially linked to hyperactivity in limbic system structures like the amygdala. Its eccentric and odd presentation fits the Cluster A category, making it a correct choice for inclusion in this group.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.