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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: A 32-year-old male with a femur fracture in traction is stable but needs ongoing pain management and monitoring for complications like infection or deep vein thrombosis (DVT). While this client requires attention, they are not in immediate critical condition compared to other patients on the list.

Choice B reason: A 38-year-old female with a grade 1 liver laceration admitted 2 days ago also requires close observation for signs of bleeding or worsening liver function. However, given that the liver laceration is of a lesser severity (grade 1), the immediate priority is less critical compared to a client with respiratory compromise.

Choice C reason: A 41-year-old male with 4 rib fractures, pneumothorax, and a chest tube is the highest priority. The presence of pneumothorax indicates a potential life-threatening condition that requires close monitoring to ensure the chest tube is functioning correctly and the lung is re-expanding. Any compromise in the chest tube's functionality can lead to respiratory distress or failure, making this client the most critical and requiring immediate assessment.

Choice D reason: A 55-year-old female admitted 6 days ago with a chest contusion and scheduled for discharge today is likely stable and does not have the same level of urgency as a client with a pneumothorax. This client needs final evaluations and discharge planning, but their condition does not present an immediate life-threatening risk.

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

The nurse is working on the step-down unit and receives the shift-to-shift report on four clients. Based on the report information, which client would be the highest priority to assess first?

Correct Answer is C

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 educating a transgender female client about the expected outcomes of estrogen therapy. Which statement made by the client would indicate the need for further teaching?

A family in the emergency department is overwhelmed at the loss of several family members due to a shooting incident in the community. Which intervention should the nurse complete first?

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?

A newly hired nurse is learning about the appropriate use of touch when communicating with clients diagnosed with psychiatric disorders. Which statement by the nurse educator best provides information about this aspect of therapeutic communication?

The nurse is working on the neurological unit. Which task would be most appropriate to delegate to the unlicensed assistive personnel assigned to the unit?