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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason: Veracity is the principle of truthfulness and honesty. It involves providing accurate information to clients and being truthful in communication. While important in healthcare, veracity does not specifically address the nurse's failure to ensure the client's safety after administering a narcotic.

Choice B reason: Autonomy refers to respecting the client's right to make their own decisions about their care. While autonomy is a fundamental ethical principle, the scenario involves the nurse's responsibility to ensure safety, which falls under a different principle.

Choice C reason: Beneficence is the principle of acting in the best interest of the client by promoting good and preventing harm. Although related to the scenario, beneficence focuses more on the proactive aspect of providing care rather than preventing harm resulting from inaction.

Choice D reason: Nonmaleficence is the ethical principle of "do no harm." The nurse violated this principle by discharging the client without ensuring they had a designated driver, leading to a motor vehicle collision and injuries. The nurse's action indirectly caused harm, violating the principle of nonmaleficence.

A. "Several staff members have commented that you are not doing your fair share of work." B. "If you are not doing your share of work, I will have to inform the nurse manager." C. "I need to talk to you about unit expectations regarding delegating and completing tasks." D. "You have been very inconsiderate of others by not completing your share of the work."

Correct Answer is C

Explanation

Choice A reason: While this statement addresses the concern, it might come across as accusatory and could put the staff nurse on the defensive. It is important to approach the situation with a focus on problem-solving rather than blame.

Choice B reason: This statement is more of a threat and may not foster a collaborative environment. It could lead to resistance rather than cooperation. The goal should be to discuss expectations and find a solution together.

Choice C reason: This statement is constructive and sets the stage for a productive conversation. It emphasizes the need to clarify unit expectations and provides an opportunity for the staff nurse to understand and meet these expectations. It focuses on the tasks and responsibilities rather than the individual's shortcomings.

Choice D reason: This statement is likely to be perceived as judgmental and may strain the working relationship. It is important to approach the situation with empathy and a focus on resolving the issue rather than criticizing the individual.

View Question and Answer

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

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

Correct Answer is D

Explanation

A charge nurse notes that a staff nurse delegates a large number of tasks to the assistive personnel (AP). The nurses on the next shift also report that the staff nurse frequently leaves tasks uncompleted. Which of the following statements should the charge nurse make to resolve this conflict?

Correct Answer is C

Explanation

The nurse and licensed practical nurse (LPN) are caring for a group of clients on a medical-surgical unit. The following tasks have been ordered on their clients. Which task would be most appropriate to assign to the LPN?

The nurse is caring for a client being prepared for a left total knee replacement surgery. The nurse is witnessing the surgeon obtain informed consent before the procedure. Which essential components must be present to obtain informed consent? (Select all that apply)

The charge nurse is planning the staff assignment for the day. Which factors should the nurse consider when planning the assignment? (Select all that apply)

A hospital is preparing to receive a large number of casualties from a community disaster. Which clients should the nurse identify as appropriate for discharge?

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)

The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor asks the nurse, "How is Mary doing? She is my best friend and is seen at your clinic every week." Which is the most appropriate nursing response?

The nurse is caring for a group of clients. After making initial rounds, which client is the nurse's priority?