A nurse approaches a hospitalized poststroke patient from the patient’s left side to do an assessment. The patient is staring straight ahead, and does not respond to the nurse’s presence or voice. Which action should the nurse take first?

Correct Answer: A

Rationale: Rationale: 1. By approaching the patient from the other side, the nurse can assess if the patient has a visual field deficit. 2. This step helps determine if the lack of response is due to a sensory issue. 3. It allows the nurse to rule out unilateral neglect or hemianopsia. 4. Walking to the other side is a basic assessment technique to evaluate visual and sensory deficits in poststroke patients. Other Choices: B. Speaking more loudly and clearly may not address the potential sensory issues the patient is experiencing. C. Waving fingers in front of the patient's face does not provide a comprehensive assessment of visual field deficits. D. Using a picture may be helpful, but addressing the potential visual field deficit should be prioritized first.

Correct Answer: C

Rationale: The correct answer is C: Bleeding gums and dark tarry stools. Thrombocytes are platelets responsible for blood clotting. Medications that depress thrombocytes can lead to decreased clotting ability, resulting in bleeding tendencies. Bleeding gums and dark tarry stools are common signs of bleeding due to decreased platelet function. A: Sore throat and swollen glands are more indicative of a possible infection or inflammation, not related to thrombocyte depression. B: Pernicious anemia with weakness is associated with vitamin B12 deficiency, not directly related to thrombocyte depression. D: Thickening of blood and bruising are not typical signs of decreased platelet function, but rather may be indicative of other conditions like clotting disorders.

Correct Answer: D

Rationale: The correct answer is D: Hyperparathyroidism. This disorder is characterized by excessive secretion of parathyroid hormone, leading to increased calcium levels in the blood. The symptoms described in the question - bone pain, weakness, irritability, and depression - are all associated with hypercalcemia, a common manifestation of hyperparathyroidism. Additionally, the client's anorexia and increased urination can be attributed to the effects of hypercalcemia on the gastrointestinal and renal systems. Diabetes mellitus (choice A) involves high blood sugar levels and is not associated with the symptoms described. Hypoparathyroidism (choice B) is characterized by low levels of parathyroid hormone and calcium, leading to different symptoms such as muscle cramps and seizures. Diabetes insipidus (choice C) is a disorder of water balance characterized by excessive thirst and urination, not the symptoms presented in the question.

Correct Answer: A

Rationale: Rationale: 1. By approaching the patient from the other side, the nurse can assess if the patient has a visual field deficit. 2. This step helps determine if the lack of response is due to a sensory issue. 3. It allows the nurse to rule out unilateral neglect or hemianopsia. 4. Walking to the other side is a basic assessment technique to evaluate visual and sensory deficits in poststroke patients. Other Choices: B. Speaking more loudly and clearly may not address the potential sensory issues the patient is experiencing. C. Waving fingers in front of the patient's face does not provide a comprehensive assessment of visual field deficits. D. Using a picture may be helpful, but addressing the potential visual field deficit should be prioritized first.

Correct Answer: B

Rationale: The correct answer is B: Severe tenderness and swelling in the scrotum. Epididymitis is characterized by inflammation of the epididymis, causing symptoms such as severe tenderness and swelling in the scrotum. Choice A is incorrect as burning and pain on urination are more indicative of a urinary tract infection. Choice C, foul-smelling ejaculate and severe scrotal swelling, is not commonly associated with epididymitis. Choice D, foul-smelling urine and pain on urination, may indicate a urinary tract infection but are not specific to epididymitis.

Correct Answer: C

Rationale: The correct answer is C because subjective data refers to information reported by the patient, such as their feelings, emotions, and perceptions. In this case, the patient describing excitement about discharge is an example of subjective data. The other choices (A, B, D) are objective data because they are observable and measurable by the nurse. Temperature (A) and wound appearance (B) are physical observations, while the patient pacing the floor (D) is a behavior that can be observed. It is important for nurses to differentiate between subjective and objective data to provide accurate assessments and care for their patients.

Correct Answer: C

Rationale: The correct answer is C: Axon. The axon is the part of the neuron that transmits impulses away from the cell body towards other neurons or target cells. It is coated with a myelin sheath, which helps speed up the transmission of impulses. Dendrites (A) receive signals from other neurons, the neurolemma (B) is the outermost layer of the myelin sheath, and the synapse (D) is the junction between two neurons where neurotransmitters are released. Therefore, the axon is the only part of the neuron specifically responsible for transmitting impulses away from the cell body.

Correct Answer: C

Rationale: Rationale: 1. Loratadine is typically dosed once daily, not twice daily, for allergic rhinitis. 2. Taking it twice daily may increase the risk of side effects without added benefit. 3. The client's dosing schedule reflects a misunderstanding of the medication regimen. 4. Option A is incorrect because loratadine is available in 10mg tablets. 5. Option B is incorrect as loratadine can be taken with or without food. 6. Option D is incorrect as Claritin is a common trade name for loratadine.

Correct Answer: A

Rationale: Rationale: - The correct answer is A, "Have you been exposed recently to anyone with an infection?" because it helps assess potential sources of infection causing the low-grade fever and other symptoms. - Choice B is irrelevant as the client's current sore throat is not the main concern. - Choice C and D do not address the potential infectious etiology of the symptoms. - Overall, assessing recent exposure to infections is crucial in identifying possible sources of the client's symptoms.