Which client warrants immediate intervention by the nurse?
a) The client with a heart rate of 56/min and a blood pressure of 110/70.
b) The client diagnosed with mitral valve regurgitation who has a thready peripheral pulse.
c) The client diagnosed with pericarditis who has chest pain with inspiration.
d) The client with a history of atrial fibrillation who has developed slurred speech.
The correct answer is: d) The client with a history of atrial fibrillation who has developed slurred speech.
Choice A reason: A heart rate of 56/min and a blood pressure of 110/70, while slightly lower than normal, may not require immediate intervention unless accompanied by other symptoms. Bradycardia (a slow heart rate) and this blood pressure reading can be within acceptable limits for some individuals, especially if they are asymptomatic.
Choice B reason: Mitral valve regurgitation with a thready peripheral pulse indicates a decrease in cardiac output, which can be concerning. However, it may not require immediate intervention unless the client shows signs of severe decompensation or other critical symptoms. Continuous monitoring and evaluation are essential, but immediate action might not be necessary.
Choice C reason: Chest pain with inspiration in a client with pericarditis can be a symptom of the condition itself, which involves inflammation of the pericardium. While pain management and monitoring are important, this symptom alone may not necessitate immediate intervention unless it is severe or accompanied by other alarming signs.
Choice D reason: The development of slurred speech in a client with a history of atrial fibrillation is a critical symptom that warrants immediate intervention. Slurred speech can be a sign of a stroke or transient ischemic attack (TI
The client with a heart rate of 56/min and a blood pressure of 110/70.
The client diagnosed with mitral valve regurgitation who has a thready peripheral pulse.
The client diagnosed with pericarditis who has chest pain with inspiration.
The client with a history of atrial fibrillation who has developed slurred speech.
The Correct Answer is D
Choice A reason: A heart rate of 56/min and a blood pressure of 110/70, while slightly lower than normal, may not require immediate intervention unless accompanied by other symptoms. Bradycardia (a slow heart rate) and this blood pressure reading can be within acceptable limits for some individuals, especially if they are asymptomatic.
Choice B reason: Mitral valve regurgitation with a thready peripheral pulse indicates a decrease in cardiac output, which can be concerning. However, it may not require immediate intervention unless the client shows signs of severe decompensation or other critical symptoms. Continuous monitoring and evaluation are essential, but immediate action might not be necessary.
Choice C reason: Chest pain with inspiration in a client with pericarditis can be a symptom of the condition itself, which involves inflammation of the pericardium. While pain management and monitoring are important, this symptom alone may not necessitate immediate intervention unless it is severe or accompanied by other alarming signs.
Choice D reason: The development of slurred speech in a client with a history of atrial fibrillation is a critical symptom that warrants immediate intervention. Slurred speech can be a sign of a stroke or transient ischemic attack (TIA), both of which require urgent medical attention. Immediate action is needed to evaluate and manage the client's condition to prevent further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Decerebrate posturing is characterized by the extension of the arms and legs, pronation of the arms, and plantar flexion. This type of posturing indicates severe brain damage, typically involving the brainstem. It is a sign of a more serious injury than decorticate posturing and suggests that the damage has progressed to affect the brainstem.
Choice B reason: Flexion withdrawal is a response to a painful stimulus where the patient pulls away from the pain. It is a reflex that indicates some level of preserved spinal cord or brainstem function. However, it does not involve the specific pattern of extension and pronation seen in decerebrate posturing.
Choice C reason: Decorticate posturing involves flexion of the arms, clenched fists, and extension of the legs. The arms are bent inward toward the body with the wrists and fingers flexed on the chest. This posturing indicates damage to the brain's cortical areas or the corticospinal tract. It is less severe than decerebrate posturing.
Choice D reason: Localization of pain is a response where the patient moves a hand towards the site of the painful stimulus, indicating a higher level of brain function. This response suggests that the brain can still process and respond to the location of the pain, which is not consistent with the described posturing.
Correct Answer is A
Explanation
Choice A reason: Carbon monoxide poisoning can cause the skin, particularly the face, to appear cherry-red. This occurs because carbon monoxide binds with hemoglobin in the blood, forming carboxyhemoglobin, which gives the skin this distinct color. It is a critical condition that requires immediate intervention as carbon monoxide displaces oxygen in the blood, leading to hypoxia and potentially life-threatening complications.
Choice B reason: Smoke inhalation is a common issue in burn victims and can cause respiratory distress, coughing, and airway irritation. However, it does not typically cause the face to turn a cherry-red color. The primary concerns with smoke inhalation are airway obstruction and lung damage rather than changes in skin color.
Choice C reason: Uremic poisoning, or uremia, results from severe kidney dysfunction and the accumulation of waste products in the blood. Symptoms can include fatigue, confusion, and a metallic taste in the mouth, but it does not cause a cherry-red discoloration of the face.
Choice D reason: Acute anemic hypertension is not a recognized medical condition. Anemia can cause pallor or a pale appearance of the skin, while hypertension typically does not cause skin discoloration. Therefore, this choice is not relevant to the described symptoms.
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