The nurse is working on the medical-surgical unit when a visiting family member reports the sudden onset of a headache and numbness on the left side of their body. The visitor asks the nurse to check their blood pressure. What is the most appropriate response by the nurse?

Assist the visitor to the emergency department

Take the visitor's blood pressure

Encourage the visitor to lie down to see if the symptoms improve

Advise the visitor to call their primary care provider

Answer and Explanation

The Correct Answer is A

Choice A reason: The sudden onset of a headache and numbness on one side of the body are potential signs of a stroke or other serious medical conditions. The most appropriate response is to assist the visitor to the emergency department for immediate evaluation and treatment. Time is critical in such scenarios, and prompt medical attention can significantly impact the outcome.

Choice B reason: While taking the visitor's blood pressure might provide some information, it is not sufficient to assess the severity of the symptoms. This action alone could delay necessary urgent care.

Choice C reason: Encouraging the visitor to lie down and see if the symptoms improve is not appropriate because it does not address the potential seriousness of the symptoms. Delaying medical evaluation could worsen the visitor's condition.

Choice D reason: Advising the visitor to call their primary care provider is not appropriate in this urgent situation. Immediate evaluation in the emergency department is necessary to rule out serious conditions like a stroke.

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Correct Answer is ["A","B","C","E"]

Explanation

Choice A reason: Confirming that the rehabilitation center has a room available at the time of transfer is essential to ensure the client has a designated space upon arrival. This helps prevent any delays or complications during the transfer process.

Choice B reason: Ensuring the client has possession of his valuables is important for safeguarding the client's personal belongings during the transfer. This task helps prevent any loss or misplacement of valuable items.

Choice C reason: Completing a transfer form for the receiving facility is a critical task that involves documenting the client's medical information, treatment plan, and other relevant details. This form ensures that the receiving facility has all the necessary information to continue the client's care seamlessly.

Choice D reason: While assessing how the client tolerates the transfer is important, it is typically done after the transfer has occurred, rather than being a responsibility of the nurse at the sending facility. This task is more relevant to the receiving facility's staff.

Choice E reason: Sending a copy of the client's chart with diagnostic and laboratory results ensures that the receiving facility has access to the client's medical history, test results, and other pertinent information. This facilitates continuity of care and informed decision-making.

A. Reassess the client when the provider arrives to obtain the informed consent. B. Notify the provider of the client's orientation. C. Call the nursing supervisor to give consent for the surgery. D. Ask another nurse to witness the informed consent.

Correct Answer is B

Explanation

Choice A reason: Reassessing the client when the provider arrives to obtain the informed consent may be necessary, but it is not the priority action. The nurse needs to ensure that the provider is aware of the client's current mental status before any attempt to obtain informed consent is made.

Choice B reason: Notifying the provider of the client's orientation is the priority action. The client's intermittent confusion indicates that she may not have the capacity to provide informed consent. The provider needs to be aware of this to take appropriate steps, such as involving a legal representative or family member, to obtain consent.

Choice C reason: Calling the nursing supervisor to give consent for the surgery is not appropriate. The nursing supervisor does not have the legal authority to provide consent on behalf of the client.

Choice D reason: Asking another nurse to witness the informed consent does not address the issue of the client's mental status and ability to provide informed consent. This action is not appropriate given the client's intermittent confusion.

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The nurse is working on the medical-surgical unit when a visiting family member reports the sudden onset of a headache and numbness on the left side of their body. The visitor asks the nurse to check their blood pressure. What is the most appropriate response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with a stroke and is scheduled for transfer to a rehabilitation center. Which of the following tasks are the responsibility of the nurse from the sending facility? (Select All that Apply)

Correct Answer is ["A","B","C","E"]

Explanation

Correct Answer is B

Explanation

The nurse is evaluating a transgender female client in the emergency department who is taking estrogen therapy. Which of the following assessment findings would be of priority concern for the nurse?

A nurse discovers that a client was administered an antihypertensive medication in error. What would be the priority action for the nurse to do first?

The nurse observes an unlicensed assistive personnel (UAP) reprimanding a client for not using the urinal properly. The UAP tells him that he will be put in a diaper if he does not use the urinal more carefully next time. Which of the following torts is the UAP committing?

A nurse is completing the admission process for an older adult client new to the unit. After gathering the assessment data and reviewing the health history, which of the following best promotes client safety?

The nurse is assessing a mechanically ventilated client with pneumonia after providing deep oral suctioning to the client. Which assessment finding would be unexpected and be a priority for the nurse to address?

The emergency department nurse is triaging clients arriving from a mass casualty incident. During the triage, the nurse confirms that each client has a disaster tag. What information should be placed on the tag for each client? (Select all that apply)