Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is planning care for several clients and is considering the clients' risk for stroke. Which of the following conditions places the client at risk for an ischemic embolic stroke?
A. A client who has an arteriovenous malformation
A client who has an arteriovenous malformation is not at risk for an ischemic embolic stroke.
B. A client who has thrombocytopenia
A client who has thrombocytopenia is not at risk for an ischemic embolic stroke.
C. A client who has chronic atrial fibrillation
A client who has chronic atrial fibrillation is at risk for an ischemic embolic stroke. An ischemic embolic stroke occurs when a blood clot that forms in one part of the body travels to the brain and blocks blood flow. Atrial fibrillation is a type of irregular heart rhythm that can cause blood to pool, thicken, and clot in the heart or arteries near it. Pieces of these clots can travel to the brain and cause an ischemic embolic stroke.
D. A client who has uncontrolled hypertension
A client who has uncontrolled hypertension is at risk for a stroke but not specifically an ischemic embolic stroke.
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Full Explanation
A client who has chronic atrial fibrillation is at risk for an ischemic embolic stroke. An ischemic embolic stroke occurs when a blood clot that forms in one part of the body travels to the brain and blocks blood flow. Atrial fibrillation is a type of irregular heart rhythm that can cause blood to pool, thicken, and clot in the heart or arteries near it. Pieces of these clots can travel to the brain and cause an ischemic embolic stroke.
a. A client who has an arteriovenous malformation is not at risk for an ischemic embolic stroke.
b. A client who has thrombocytopenia is not at risk for an ischemic embolic stroke.
d. A client who has uncontrolled hypertension is at risk for a stroke but not specifically an ischemic embolic
stroke.
Similar Questions
A nurse is reinforcing teaching with a client who has an ankle sprain. Which of the following instructions should the nurse include?
A. Apply the elastic compression dressing tight enough so the toes and ankle become numb.
The elastic compression dressing should not be applied so tight that it causes numbness in the toes and ankle.
B. Place moderate weight on the affected leg when walking.
The client should avoid placing weight on the affected leg when walking until advised by a healthcare provider.
C. Elevate the affected ankle to the level of the heart.
The nurse should instruct the client to elevate the affected ankle to the level of the heart. Elevation helps to reduce swelling and pain by promoting venous return and decreasing blood flow to the injured area. This is an important part of the RICE (Rest, Ice, Compression, Elevation) method for treating sprains and strains.
D. Apply heat during the first 24 hr.
Heat should not be applied during the first 24 hours after a sprain as it can increase swelling and inflammation.
Full Explanation
The nurse should instruct the client to elevate the affected ankle to the level of the heart. Elevation helps to reduce swelling and pain by promoting venous return and decreasing blood flow to the injured area. This is an important part of the RICE (Rest, Ice, Compression, Elevation) method for treating sprains and strains.
a. The elastic compression dressing should not be applied so tight that it causes numbness in the toes and ankle.
b. The client should avoid placing weight on the affected leg when walking until advised by a healthcare provider.
d. Heat should not be applied during the first 24 hours after a sprain as it can increase swelling and inflammation.
A nurse is collecting data from a client who has a short arm cast for a fractured wrist. Which of the following findings indicates impaired venous return in the affected arm?
A. Auscultation of lungs revealing wheezing
Auscultation of lungs revealing wheezing is not related to venous return in the affected arm. Wheezing is a high-pitched whistling sound made while breathing and is usually a sign of a respiratory problem.
B. A bounding distal pulse
A bounding distal pulse indicates strong arterial blood flow, which is not a sign of impaired venous return. Impaired venous return would more likely result in a weak or absent pulse.
C. Fever
Fever could indicate infection but is not specific to impaired venous return. It's a systemic sign that may or may not be related to the cast or the fracture.
D. Pain unrelieved by opioid analgesic
Pain that is unrelieved by opioid analgesics can be a sign of compartment syndrome, which is a serious complication that can result from impaired venous return and increased pressure within the muscle compartments. This requires immediate medical attention to prevent permanent damage.
Full Explanation
a. Auscultation of lungs revealing wheezing is not related to venous return in the affected arm. Wheezing is
a high-pitched whistling sound made while breathing and is usually a sign of a respiratory problem.
b. A bounding distal pulse indicates strong arterial blood flow, which is not a sign of impaired venous return. Impaired venous return would more likely result in a weak or absent pulse.
c. Fever could indicate infection but is not specific to impaired venous return. It's a systemic sign that may or may not be related to the cast or the fracture.
d. Pain that is unrelieved by opioid analgesics can be a sign of compartment syndrome, which is a serious complication that can result from impaired venous return and increased pressure within the muscle compartments. This requires immediate medical attention to prevent permanent damage.
A nurse is collecting data from a client who has increased intracranial pressure and is informed by the charge nurse that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe?
A. Extension of the extremities
Decorticate posturing is marked by the flexion of the arms, with the hands clenched into fists and the legs extended and internally rotated.
B. External rotation of the lower extremities
External rotation of the lower extremities is not a characteristic of decorticate posturing. In decorticate posture, legs are held out straight.
C. Pronation of the hands
Pronation of the hands is characteristic of decerebrate posturing, where the arms are extended and pronated.
D. Plantar flexion of the legs
In decorticate posturing, the lower extremities typically exhibit plantar flexion. Additionally, the upper extremities show flexion of the arms, wrists, and fingers with adduction of the arms.
Full Explanation
a. Decorticate posturing is marked by the flexion of the arms, with the hands clenched into fists and the legs extended and internally rotated.
b. External rotation of the lower extremities is not a characteristic of decorticate posturing. In decorticate posture, legs are held out straight.
c. Pronation of the hands is characteristic of decerebrate posturing, where the arms are extended and pronated.
d. In decorticate posturing, the lower extremities typically exhibit plantar flexion. Additionally, the upper extremities show flexion of the arms, wrists, and fingers with adduction of the arms.
