Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse is caring for a client who reports sudden right-sided numbness and weakness of the arm and leg. The nurse also observes a distinct right-sided facial droop. After reporting the findings to the healthcare provider, the nurse receives several prescriptions for the client, including a STAT computerized tomography scan of the head.
After obtaining vital signs, the nurse should implement which intervention?
A. Keep the bed in the lowest position and initiate seizure and fall precautions.
While keeping the bed in the lowest position and initiating seizure and fall precautions may be important considerations for stroke patients, notifying the stroke team takes precedence as they are specifically trained to manage acute stroke cases.
B. Administer aspirin to prevent further clot formation and platelet clumping.
Administering aspirin to prevent further clot formation and platelet clumping is not appropriate without further assessment and confirmation of the type of stroke.
C. Notify the stroke team to assist with acute assessment and management.
Based on the client's sudden right-sided numbness, weakness of the arm and leg, and distinct right-sided facial droop, the nurse should suspect a possible stroke and prioritize immediate interventions. After reporting the findings to the healthcare provider and receiving prescriptions, the nurse should implement the following intervention: Notify the stroke team to assist with acute assessment and management. A stroke is a medical emergency that requires urgent intervention and specialized care. The stroke team is trained to quickly assess and manage stroke patients, including performing necessary diagnostic tests and initiating appropriate treatment. In this case, a STAT computerized tomography (CT) scan of the head has been ordered, indicating the need to evaluate the client's brain for possible ischemic or hemorrhagic stroke.
D. Test for a swallowing reflex and perform communication deficit assessments.
Additionally, testing for a swallowing reflex and performing communication deficit assessments can be important components of the overall stroke management plan, but they should be carried out by the stroke team or as directed by the healthcare provider.
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Full Explanation
Based on the client's sudden right-sided numbness, weakness of the arm and leg, and distinct right-sided facial droop, the nurse should suspect a possible stroke and prioritize immediate interventions. After reporting the findings to the healthcare provider and receiving prescriptions, the nurse should implement the following intervention:
Notify the stroke team to assist with acute assessment and management. A stroke is a medical emergency that requires urgent intervention and specialized care. The stroke team is trained to quickly assess and manage stroke patients, including performing necessary diagnostic tests and initiating appropriate treatment. In this case, a STAT computerized tomography (CT) scan of the head has been ordered, indicating the need to evaluate the client's brain for possible ischemic or hemorrhagic stroke.
While keeping the bed in the lowest position and initiating seizure and fall precautions may be important considerations for stroke patients, notifying the stroke team takes precedence as they are specifically trained to manage acute stroke cases.
Administering aspirin to prevent further clot formation and platelet clumping is not appropriate without further assessment and confirmation of the type of stroke.
Additionally, testing for a swallowing reflex and performing communication deficit assessments can be important components of the overall stroke management plan, but they should be carried out by the stroke team or as directed by the healthcare provider.
Similar Questions
A nurse at a health department is providing anticipatory guidance to the parent of a 1-month-old infant.
The nurse should inform the parent that the infant should receive which of the following immunizations at the age of 2 months?
A. Varicella.
Varicella vaccine is typically administered to children at the age of 1 year, not at 2 months. The first dose of varicella vaccine is usually given at 12-15 months of age, with a second dose recommended at 4-6 years of age.
B. Rotavirus.
Rotavirus vaccine is typically administered to infants at 2 months of age. The other options mentioned (Varicella, Influenza, and Hepatitis A) are not usually given at 2 months of age. However, immunization recommendations may change over time, so it's essential to follow the guidelines provided by your local health department and consult with your healthcare provider for the most current information.
C. Influenza.
Influenza vaccine is not typically administered to infants at 2 months of age. Influenza vaccination is recommended annually for children older than 6 months.
D. Hepatitis A.
Hepatitis A vaccine is not routinely given at 2 months of age. Hepatitis A vaccination is typically recommended starting at 1 year of age, with a second dose administered 6-18 months later.
Full Explanation
Choice A rationale:
Varicella vaccine is typically administered to children at the age of 1 year, not at 2 months. The first dose of varicella vaccine is usually given at 12-15 months of age, with a second dose recommended at 4-6 years of age.
Choice B rationale:
Rotavirus vaccine is recommended to be administered to infants at the age of 2 months. It is an oral vaccine that protects against rotavirus infections, a common cause of severe diarrhea and dehydration in infants and young children.
Choice C rationale:
Influenza vaccine is not typically administered to infants at 2 months of age. Influenza vaccination is recommended annually for children older than 6 months.
Choice D rationale:
Hepatitis A vaccine is not routinely given at 2 months of age. Hepatitis A vaccination is typically recommended starting at 1 year of age, with a second dose administered 6-18 months later.
A nurse is monitoring a client who is receiving a transfusion of packed RBCs.
The client reports chills, headache, low-back pain, and a feeling of "tightness" in his chest.
The nurse should identify that the client has developed which of the following types of transfusion reactions?
A. Allergic.
Allergic transfusion reactions are characterized by symptoms such as hives, itching, and shortness of breath. While allergic reactions can cause discomfort, they do not typically present with the symptoms described in the scenario, such as chills, headache, low-back pain, and chest tightness.
B. Febrile nonhemolytic.
Febrile nonhemolytic transfusion reactions are characterized by fever and chills, but they do not usually cause headache, low-back pain, or chest tightness. These reactions occur due to antibodies against donor leukocytes or platelets.
C. Acute hemolytic.
Acute hemolytic transfusion reactions occur when there is a mismatch in blood type between the donor and recipient, leading to rapid destruction of transfused red blood cells. This reaction can cause symptoms such as chills, fever, low-back pain, chest tightness, and hemoglobinuria (presence of hemoglobin in the urine) It is a medical emergency that requires immediate cessation of the transfusion, supportive care, and treatment for potential complications such as acute kidney injury.
D. Bacterial.
Bacterial transfusion reactions occur due to bacterial contamination of the blood product. These reactions can cause symptoms such as fever, chills, hypotension, and shock. While bacterial transfusion reactions can be serious, the symptoms described in the scenario, including headache and low-back pain, are not typically associated with this type of reaction.
Full Explanation
Choice A rationale:
Allergic transfusion reactions are characterized by symptoms such as hives, itching, and shortness of breath. While allergic reactions can cause discomfort, they do not typically present with the symptoms described in the scenario, such as chills, headache, low-back pain, and chest tightness.
Choice B rationale:
Febrile nonhemolytic transfusion reactions are characterized by fever and chills, but they do not usually cause headache, low-back pain, or chest tightness. These reactions occur due to antibodies against donor leukocytes or platelets.
Choice C rationale:
Acute hemolytic transfusion reactions occur when there is a mismatch in blood type between the donor and recipient, leading to rapid destruction of transfused red blood cells. This reaction can cause symptoms such as chills, fever, low-back pain, chest tightness, and hemoglobinuria (presence of hemoglobin in the urine) It is a medical emergency that requires immediate cessation of the transfusion, supportive care, and treatment for potential complications such as acute kidney injury.
Choice D rationale:
Bacterial transfusion reactions occur due to bacterial contamination of the blood product. These reactions can cause symptoms such as fever, chills, hypotension, and shock. While bacterial transfusion reactions can be serious, the symptoms described in the scenario, including headache and low-back pain, are not typically associated with this type of reaction.
A nurse is teaching the parents of a school-age child who has sickle cell anemia about managing the disease at home.
Which of the following instructions should the nurse include?
A. Report sudden, persistent headaches.
The nurse should instruct the parents to report sudden, persistent headaches in a child with sickle cell anemia because it could be a sign of a cerebrovascular accident (stroke) Sickle cell anemia predisposes individuals to vaso-occlusive crises, which can lead to stroke due to impaired blood flow. Early detection and intervention are crucial in preventing complications.
B. Apply cold compresses to painful areas.
Applying cold compresses to painful areas may help in managing pain during vaso-occlusive crises, but it is not as critical as identifying signs of more severe complications such as stroke. This instruction does not address the urgency of reporting sudden, persistent headaches.
C. Restrict fluid intake during times of stress.
Restricting fluid intake during times of stress is not appropriate for a child with sickle cell anemia. In fact, maintaining adequate hydration is important to prevent vaso-occlusive crises. Dehydration can exacerbate sickling of red blood cells, leading to more pain and complications.
D. Avoid meningococcal immunizations.
Avoiding meningococcal immunizations is not appropriate for a child with sickle cell anemia. In fact, children with sickle cell disease are at an increased risk of infections, including meningitis. Immunizations, including those for meningococcus, are essential to prevent life-threatening infections in these individuals.
Full Explanation
Choice A rationale:
The nurse should instruct the parents to report sudden, persistent headaches in a child with sickle cell anemia because it could be a sign of a cerebrovascular accident (stroke) Sickle cell anemia predisposes individuals to vaso-occlusive crises, which can lead to stroke due to impaired blood flow. Early detection and intervention are crucial in preventing complications.
Choice B rationale:
Applying cold compresses to painful areas may help in managing pain during vaso-occlusive crises, but it is not as critical as identifying signs of more severe complications such as stroke. This instruction does not address the urgency of reporting sudden, persistent headaches.
Choice C rationale:
Restricting fluid intake during times of stress is not appropriate for a child with sickle cell anemia. In fact, maintaining adequate hydration is important to prevent vaso-occlusive crises. Dehydration can exacerbate sickling of red blood cells, leading to more pain and complications.
Choice D rationale:
Avoiding meningococcal immunizations is not appropriate for a child with sickle cell anemia. In fact, children with sickle cell disease are at an increased risk of infections, including meningitis. Immunizations, including those for meningococcus, are essential to prevent life-threatening infections in these individuals.