A nurse is caring for a patient with a history of stroke. The nurse should monitor for which of the following complications?

Correct Answer: B

Rationale: The correct answer is B: Deep vein thrombosis (DVT). Patients with a history of stroke are at increased risk for DVT due to immobility and potential damage to blood vessels. Monitoring for DVT is crucial to prevent life-threatening complications like pulmonary embolism. Pulmonary embolism (A) is a potential complication of DVT but not the most direct concern. Hypertension (C) is a common condition but not directly linked to a history of stroke. Hyperglycemia (D) is more commonly associated with diabetes rather than stroke history. Monitoring for DVT in stroke patients is essential for early detection and intervention.

Correct Answer: B

Rationale: The correct first intervention for a client suspected of having a stroke is to perform a CT scan (Choice B). This is because a CT scan can quickly identify the type of stroke (ischemic or hemorrhagic) and guide treatment decisions. Monitoring neurological status (Choice A) can be important but does not provide a definitive diagnosis. Administering fibrinolytics (Choice C) should only be done after confirming the type of stroke to avoid complications. Performing an MRI (Choice D) is more time-consuming and may not be feasible in the acute setting where quick intervention is crucial. Therefore, a CT scan is the most appropriate initial intervention for a suspected stroke.

Correct Answer: A

Rationale: The correct answer is A: variable decelerations. Variable decelerations are abrupt decreases in fetal heart rate that vary in depth, duration, and timing, which can indicate cord compression. The variability in these decelerations suggests that the umbilical cord is being compressed intermittently. Early decelerations (B) are usually caused by head compression during contractions and mirror the contractions, not indicating cord compression. Bradycardia (C) is a slow heart rate, which can be caused by various factors but is not specific to cord compression. Tachycardia (D) is a fast heart rate, which can also be caused by various factors but is not typically associated with cord compression.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. Oxygenation is the priority in stroke management to ensure adequate oxygen supply to the brain. Oxygen therapy can help reduce hypoxia, which is crucial in the acute phase of a stroke. Administering aspirin (B) is important but comes after ensuring oxygenation. Administering thrombolytics (C) requires proper assessment and diagnostic confirmation, not an immediate priority. Placing the client in a supine position (D) may worsen stroke symptoms if there is compromised blood flow, so it is not recommended as the initial action.

Correct Answer: A

Rationale: The correct answer is A: Administer antibiotics. Peritonitis is an inflammation of the peritoneum often caused by infection. Administering antibiotics is crucial to combat the infection. It is important to treat the underlying cause first before focusing on symptom management. Administering analgesics (B) may provide temporary relief but won't address the infection. Applying an ice pack (C) is not appropriate for peritonitis as it won't treat the infection. Performing a laparotomy (D) is a surgical procedure that may be necessary in severe cases but is not the initial nursing action.

Correct Answer: A

Rationale: The correct answer is A: Psoriasis. Psoriasis is characterized by red, scaly patches on the skin, which align with the symptoms described. Psoriasis commonly affects the lower legs and is associated with severe itching. Eczema (choice B) is characterized by red, inflamed, and itchy skin patches, but typically presents differently from psoriasis. Contact dermatitis (choice C) is a localized reaction that occurs when the skin comes into contact with an irritant or allergen, and fungal infections (choice D) typically present with itching, redness, and sometimes peeling skin, but not necessarily scaly patches like psoriasis.

Correct Answer: A

Rationale: The correct answer is A: Transfuse neutrophils. Neutrophil transfusion is not a standard treatment for neutropenia as neutrophils do not survive well outside the body. For the other choices: B: Excluding raw vegetables is correct to prevent infection. C: Avoiding rectal suppositories is correct to prevent mucosal injury. D: Prohibiting vases of fresh flowers is correct to prevent exposure to fungal spores. So, transfusing neutrophils is inappropriate as it is not a standard treatment for neutropenia.

Correct Answer: A

Rationale: The correct answer is A: Administer albuterol. Albuterol is a bronchodilator that helps open the airways, relieving wheezing in asthma patients. It is the first-line treatment for acute asthma exacerbations. Antihistamines (B) do not treat asthma symptoms. Monitoring for infection (C) is important but not the immediate action for wheezing. Epinephrine (D) is used for severe allergic reactions, not routine asthma management.

Correct Answer: A

Rationale: Step-by-step rationale for choosing Albuterol as the correct answer: 1. Albuterol is a rapid-acting bronchodilator that provides immediate relief by relaxing the airway muscles during asthma exacerbation. 2. It is the first-line medication recommended by guidelines for acute asthma attacks due to its quick onset of action. 3. Albuterol helps in opening the airways, improving airflow, and relieving symptoms like shortness of breath and wheezing. 4. Epinephrine is not the first choice for asthma exacerbation as it can have more systemic side effects. 5. Levalbuterol is a similar medication to Albuterol but may not be as widely available or cost-effective. 6. IV corticosteroids are important for long-term control but take longer to show effects, making them less suitable as the initial treatment for acute exacerbation.