You are caring for a client in the ED with B/P 254/139 mm Hg. Which of the following actions would you take first?

Elevate the head of the client’s bed

Contact the Rapid Response Team

Tell the client to report vision changes

Insert a peripheral IV

Initiate seizure precautions

Answer and Explanation

The Correct Answer is B

Choice A reason:

Elevating the head of the client’s bed can help reduce blood pressure slightly by promoting venous return and decreasing intracranial pressure. However, this action alone is not sufficient to address the severe hypertension (254/139 mm Hg) the client is experiencing. Immediate medical intervention is required to prevent complications such as stroke, heart attack, or organ damage.

Choice B reason:

Contacting the Rapid Response Team is the highest priority action. The Rapid Response Team is trained to handle critical situations and can provide immediate interventions to stabilize the client’s condition. Severe hypertension at this level requires urgent medical attention to prevent life-threatening complications. The team can administer medications to lower blood pressure quickly and monitor the client closely.

Choice C reason:

Telling the client to report vision changes is important because vision changes can indicate hypertensive retinopathy or increased intracranial pressure. However, this action is not the immediate priority. The client’s blood pressure needs to be controlled urgently to prevent further complications.

Choice D reason:

Inserting a peripheral IV is necessary for administering medications and fluids. While this is an important step, it should follow the immediate action of contacting the Rapid Response Team. The team can then use the IV access to administer antihypertensive medications promptly.

Choice E reason:

Initiating seizure precautions is important because severe hypertension can lead to seizures. However, this action is not the first priority. The primary focus should be on stabilizing the client’s blood pressure through immediate medical intervention.

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Correct Answer is A

Explanation

Choice A: He is NPO until the speech-language pathologist performs a swallowing evaluation.

When a client is admitted with a stroke, especially one affecting the left side, there is a significant risk of dysphagia, or difficulty swallowing. This can lead to choking and aspiration, which can cause pneumonia and other complications. Therefore, it is crucial to keep the client NPO (nothing by mouth) until a speech-language pathologist can perform a thorough swallowing evaluation. This ensures that the client can safely swallow without the risk of aspiration. The speech-language pathologist will assess the client’s ability to swallow different textures and consistencies of food and liquids and provide recommendations for safe feeding.

Choice B: Be sure to sit him up when you are feeding him to make him feel more natural.

While sitting the client up during feeding is a good practice to reduce the risk of aspiration, it is not sufficient on its own for a client who has just had a stroke. Without a proper swallowing evaluation, feeding the client could still pose a significant risk. Therefore, this choice is not the most appropriate response.

Choice C: You may give him a full-liquid diet, but please avoid solid foods until he gets stronger.

A full-liquid diet might seem like a safer option, but it still poses a risk of aspiration if the client has dysphagia. Without a swallowing evaluation, it is not safe to assume that the client can handle even a full-liquid diet. Therefore, this choice is not appropriate.

Choice D: Just be sure to add some thickener in his liquids to prevent choking and aspiration.

Adding thickener to liquids can help some clients with dysphagia, but it is not a one-size-fits-all solution. The appropriate consistency of liquids should be determined by a speech-language pathologist after a swallowing evaluation. Therefore, this choice is not appropriate without a prior assessment.

A. Weight gain B. Low-grade fever C. Dyspnea D. Contusion E. Lethargy F. Night sweats

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

Explanation

Choice A Reason:

Weight gain is not typically associated with tuberculosis (TB). In fact, weight loss is a common symptom of TB due to the chronic nature of the infection and the body’s increased metabolic demands to fight the disease. Patients with TB often experience a loss of appetite and significant weight loss as the disease progresses.

Choice B Reason:

Low-grade fever is a common symptom of TB. The body’s immune response to the infection often results in a persistent low-grade fever, which can be one of the early signs of the disease. This fever is usually accompanied by other systemic symptoms such as night sweats and fatigue.

Choice C Reason:

Dyspnea, or difficulty breathing, can occur in patients with TB, especially if the infection has caused significant lung damage or if there is a large amount of fluid in the pleural space (pleural effusion). Dyspnea is a concerning symptom that indicates the need for further evaluation and treatment.

Choice D Reason:

Contusion, or bruising, is not a symptom associated with TB. TB primarily affects the lungs and can cause systemic symptoms, but it does not typically cause bruising. Contusions are more commonly associated with trauma or conditions that affect blood clotting.

Choice E Reason:

Lethargy, or a general sense of fatigue and weakness, is a common symptom of TB. The chronic nature of the infection and the body’s ongoing immune response can lead to significant fatigue. Patients with TB often feel tired and may have difficulty performing daily activities.

Choice F Reason:

Night sweats are a hallmark symptom of TB. Patients often experience drenching night sweats that can be quite severe. This symptom, along with fever and weight loss, is part of the classic triad of TB symptoms and is an important indicator for healthcare providers to consider TB in the differential diagnosis.

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You are caring for a client in the ED with B/P 254/139 mm Hg. Which of the following actions would you take first?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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

Explanation

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