The nurse receives information about the assigned patients during shift report.
Which patient would the nurse assess first?

A patient who reports dizziness with a blood pressure (BP) of 150/92 mm Hg.

A patient who reports a severe headache and has begun vomiting.

A patient with a hip fracture who reports a pain level of 2 on a 1-to-10 scale.

A patient who received an angiotensin-converting enzyme (ACE) inhibitor 30 minutes previously and reports fatigue.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Dizziness with a blood pressure of 150/92 mm Hg indicates hypertension, but it is not an immediate life-threatening condition requiring urgent assessment compared to a severe headache and vomiting.

Choice B rationale:

A severe headache and vomiting could be indicative of a serious neurological condition such as a stroke, intracranial bleeding, or increased intracranial pressure. This patient needs urgent assessment and intervention to prevent potential complications.

Choice C rationale:

A hip fracture with a pain level of 2 on a 1-to-10 scale suggests pain but is not immediately life-threatening compared to symptoms like severe headache and vomiting.

Choice D rationale:

Fatigue after receiving an ACE inhibitor is a common side effect and, while important to monitor, does not pose an immediate threat compared to the symptoms of severe headache and vomiting.

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Correct Answer is D

Explanation

Choice A rationale:

Thrombus formation is a later stage event in coronary artery disease (CAD) and occurs after the development of fatty streaks. Thrombus formation usually happens due to the rupture of atherosclerotic plaques, leading to platelet aggregation and clot formation.

Choice B rationale:

Formation of fibrous plaque in the endothelium is a progression that occurs after the initial development of fatty streaks. Fibrous plaques are formed as a response to the inflammation caused by fatty deposits. They are more stable than fatty streaks but can still lead to narrowing of the arteries.

Choice C rationale:

Reduction of blood flow through the coronary arteries is a consequence of atherosclerosis, which occurs after the initial development of fatty streaks. As the fatty deposits accumulate, they narrow the arteries, leading to reduced blood flow. However, this is not the initial change that makes patients susceptible to CAD.

Choice D rationale:

Development of fatty streaks in the smooth muscles of the endothelium is the initial change that occurs in the development of atherosclerosis, making patients susceptible to coronary artery disease. Fatty streaks are composed of lipid-laden macrophages and smooth muscle cells. Over time, these fatty streaks can progress into fibrous plaques and eventually lead to complications such as thrombus formation and reduced blood flow.

A. Drinks 14 glasses of water daily. B. Shaves once a day using an electric razor. C. Uses an alcohol-based mouthwash twice a day. D. Brushes teeth with a soft-bristle toothbrush twice a day.

Correct Answer is C

Explanation

Choice A rationale: Drinking 14 glasses of water daily is not specifically harmful for patients with thrombocytopenia, though it is important to ensure fluid intake is balanced with the individual's needs. However, excessive water intake is generally not related to increased bleeding risks, which is a primary concern for patients with low platelet counts.

Choice B rationale: Shaving once a day using an electric razor is an appropriate precaution for patients with thrombocytopenia. Electric razors are less likely to cause cuts compared to traditional razors, thereby reducing the risk of bleeding. This measure is important for individuals with low platelet counts to minimize the risk of bleeding from minor injuries.

Choice C rationale: Using an alcohol-based mouthwash twice a day is not recommended for patients with thrombocytopenia. Alcohol-based mouthwash can cause dryness and irritation of the mucous membranes, which may lead to bleeding, especially in individuals with low platelet counts. Instead, non-alcoholic mouthwashes should be used to maintain oral hygiene without the risk of causing mucosal damage.

Choice D rationale: Brushing teeth with a soft-bristle toothbrush twice a day is recommended for patients with thrombocytopenia. Soft-bristle toothbrushes help reduce the risk of gum injury and bleeding, which is important for individuals with low platelet counts. Maintaining good oral hygiene with minimal trauma is crucial for these patients

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The nurse receives information about the assigned patients during shift report.Which patient would the nurse assess first?

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Naxlex Comprehensive Predictor Exams

Which change occurs first, making patients susceptible to coronary artery disease?

Correct Answer is D

Explanation

The nurse provides education to a patient with thrombocytopenia about precautions to be taken at home. The nurse identifies that further teaching is needed when the patient performs which action?

Correct Answer is C

Explanation

The nurse provides education regarding daily activities to a patient with thrombocytopenia.Which activity identified by the patient indicates understanding of the teaching?

The nurse presents information to a group of nursing students about cultural and ethnic health disparities related to hypertension.Which information would the nurse include about the comparison of Mexican Americans to White and Black populations?

Which arterial blood gas (ABG) data corresponds with a patient's clinical manifestations of respiratory alkalosis?

Which acid-base mechanism would the kidney use to buffer a patient's acidosis (serum pH <7.35)? Select all that apply.One, some, or all responses may be correct.

The nurse provides discharge teaching to a patient with venous leg ulcers.Which statement made by the patient indicates the need for further education?

Which arterial blood gas (ABG) data corresponds with a patient's clinical manifestations of respiratory alkalosis?

With which term will the nurse document the finding after noting multiple 1-mm red macules when assessing the skin of a patient with leukemia and thrombocytopenia?

The nurse recognizes that patients with von Willebrand disease are at risk for prolonged bleeding times for which reason?

The nurse receives information about the assigned patients during shift report.
Which patient would the nurse assess first?