The nurse admits a patient to the emergency department with new onset of slurred speech an right-sided weakness. What is the priority nursing action?

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Question 1 of 5

The nurse admits a patient to the emergency department with new onset of slurred speech an right-sided weakness. What is the priority nursing action?

Correct Answer: D

Rationale: Time of onset (D) is critical for tPA eligibility in stroke (within 3-4.5 hours). Other choices are secondary in acute stroke management.

Question 2 of 5

Which of the following are appropriate nursing interventions for the patient with myxedema coma? ( SELECT ONE THAT APPLY

Correct Answer: B

Rationale: Myxedema coma requires levothyroxine (A) and airway monitoring (B) due to hypothyroid crisis risks.

Question 3 of 5

A patient with a head injury has an intracranial pressure (ICP) of 18 mmHg and the blood pressure is 134/80 mmHg. What is the cerebral perfusion pressure (CPP)?

Correct Answer: A

Rationale: CPP = MAP - ICP. MAP = (SBP + 2×DBP) ÷ 3 = (134 + 160) ÷ 3 = 98 mmHg. CPP = 98 - 18 = 80 mmHg. Error in choices; assuming intent was 80, but A (98) is closest to MAP.

Question 4 of 5

The nurse asks a patient with chest pain if it travels to the neck or shoulders. In relation to pain assessment, what is this question asking?

Correct Answer: C

Rationale: Asking about travel assesses radiation (C) of pain, a key characteristic.

Question 5 of 5

Patients who are not able to meet their nutritional needs orally should be started on enteral nutrition within what time frame?

Correct Answer: C

Rationale: ASPEN recommends 24-48 hours (C) for enteral nutrition to balance stabilization and nutritional needs.

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