A patient is hospitalized following a stroke. Three days after admission, the patient is able to converse clearly with the nurse during the morning assessment. Early in the afternoon, the patient's daughter runs out of the room and says, "My mother can't talk. Somebody help!" Which response by the nurse is best?

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Question 1 of 5

A patient is hospitalized following a stroke. Three days after admission, the patient is able to converse clearly with the nurse during the morning assessment. Early in the afternoon, the patient's daughter runs out of the room and says, "My mother can't talk. Somebody help!" Which response by the nurse is best?

Correct Answer: B

Rationale: The best response by the nurse in this situation would be to do a quick assessment to confirm the change in the patient's status and then notify the registered nurse (RN) or physician. It is essential for the healthcare team to promptly assess and address any sudden changes in a stroke patient's condition, such as the sudden inability to speak. This could indicate a serious issue that requires immediate attention and intervention. By quickly assessing the patient's status and notifying the appropriate healthcare provider, the nurse can ensure that the patient receives the necessary care and interventions in a timely manner.

Question 2 of 5

Which of the ff. nursing interventions will help prevent complications in the patient with Bell's Palsy?

Correct Answer: D

Rationale: Bell's Palsy is a condition that affects the facial nerve, leading to weakness or paralysis of the facial muscles. One common complication of Bell's Palsy is the inability to fully close the affected eye, which can result in corneal exposure and dryness. Lubricating eye drops help prevent dryness and protect the cornea from damage due to inadequate eye closure. Using lubricating eye drops regularly can help maintain the eye's moisture and prevent potential complications such as corneal abrasions and infections, which are common in patients with Bell's Palsy. Megavitamin therapy, application of ice, and elastic bandages are not typically indicated for preventing complications in patients with Bell's Palsy.

Question 3 of 5

Mr. RR is admitted to the hospital with a diagnosis of brain tumor. Mr. RR's doctor is very much concerned about the possibility of increased intracranial pressure. The following is the most reliable index of cerebral state:

Correct Answer: A

Rationale: The most reliable index of cerebral state in a patient diagnosed with a brain tumor and concerning increased intracranial pressure is the level of consciousness. Changes in consciousness, such as alterations in alertness, orientation, and responsiveness, are significant indicators of the brain's functioning and can provide valuable insights into the impact of increased intracranial pressure. Monitoring the level of consciousness helps healthcare providers assess neurological status and make critical decisions regarding the management of intracranial pressure. Unilateral papillary dilatation, increased systolic blood pressure, and decreased pulse pressure may also be important indicators but are not as reliable or direct as changes in the level of consciousness when evaluating cerebral status in this context.

Question 4 of 5

The examiner shines a light in the patient's eyes and notes that the pupils are round and constrict from 4 to 2 mm bilaterally. Next, the examiner asks the patient to focus on a far object, then on the examiner's finger as it is brought from 3 feet distance to 5 inches distance. The pupils constrict bilaterally and the eyes turn inward. Which of the ff. would be the correct documentation of these findings?

Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 5 of 5

Which of the ff. nursing interventions would have the highest priority in the plan of care for the postoperative eye patient?

Correct Answer: C

Rationale: In the postoperative period for an eye patient, sudden onset of acute pain can be indicative of a complication or an issue that needs immediate attention. Promptly reporting and addressing the pain is essential to prevent any further complications, such as infection, corneal abrasion, or increased intraocular pressure. This intervention takes priority over the other options listed as it involves the patient's immediate safety and well-being. It is crucial to follow postoperative protocols and report any unexpected or severe symptoms to ensure appropriate treatment and prevent any potential harm to the patient's eyesight.

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