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: B

Rationale: The correct answer is B because it encourages the patient to share any additional information they may have forgotten or overlooked, ensuring a thorough health history interview. Choice A is incorrect as it implies the interviewer is unprepared or disinterested. Choice C is inappropriate as it may make the patient feel guilty or inadequate. Choice D is incorrect as it does not address the possibility of gathering more relevant information from the patient.

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: C

Rationale: The correct answer is C because subjective data refers to information provided by the patient, such as their feelings, perceptions, and symptoms. In this case, the patient describing excitement about discharge is subjective as it is based on their personal experience. The other options (A, B, D) are objective data as they can be measured or observed directly without interpretation. The patient's temperature (A) and wound appearance (B) are physical observations, while the patient pacing the floor (D) is a behavior that can be observed. Therefore, only choice C fits the definition of subjective data in a nursing assessment.

Correct Answer: D

Rationale: The correct answer is D because morphine helps in acute pulmonary edema by decreasing peripheral resistance, pulmonary capillary pressure, and transudation of fluid. Morphine causes vasodilation, reducing peripheral resistance, which helps redistribute blood flow to the periphery. It also reduces pulmonary capillary pressure by decreasing preload and afterload, leading to decreased fluid transudation into the alveoli. Choices A, B, and C individually do not cover all the effects of morphine in acute pulmonary edema, making them incorrect.

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.

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: D

Rationale: The correct answer is D: Eight Cranial Nerve (Vestibulocochlear). This nerve is responsible for hearing and balance. Ringing noises indicate a disturbance in hearing function. The other choices are incorrect because: A: Frontal lobe is associated with executive functions, not hearing. B: Six cranial nerve (abducent) controls eye movement. C: Occipital lobe is related to vision, not hearing. Therefore, the correct choice is D as it directly relates to the symptom described.

Correct Answer: C

Rationale: The correct answer is C: Tactile agnosia. When assessing a client with a parietal lobe brain tumor, the nurse would expect to assess for tactile agnosia as the parietal lobe is responsible for processing sensory information, including touch and spatial awareness. Tactile agnosia is the inability to recognize objects by touch. This impairment is commonly associated with parietal lobe lesions. Short-term memory impairment (A) is more commonly associated with temporal lobe lesions. Seizures (B) are more commonly associated with frontal lobe lesions. Contralateral homonymous hemianopia (D) is associated with occipital lobe lesions. In summary, the parietal lobe tumor would likely manifest as tactile agnosia due to its role in sensory processing, making it the most relevant assessment finding in this scenario.