The nurse working in the ER uses which diagnostic scale to assess the severity of presenting signs and symptoms of stroke?

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Neurological Disorders in Medical Surgical Nursing Questions

Question 1 of 5

The nurse working in the ER uses which diagnostic scale to assess the severity of presenting signs and symptoms of stroke?

Correct Answer: C

Rationale: The NIH Stroke Scale (NIHSS) quantifies stroke severity in the ER, assessing consciousness, motor function, etc. Cincinnati scale is for prehospital screening, Glasgow is for outcomes. Choice C is correct.

Question 2 of 5

A nurse is caring for a client who has type 2 diabetes mellitus and is experiencing a hyperglycemia hyperosmolar state (HHS). Which of the following laboratory finding should the nurse expect?

Correct Answer: D

Rationale: HHS typically has normal pH (7.45, D) and very high glucose (>600 mg/dL), but C (425) is closer than B.

Question 3 of 5

An important nursing intervention for the patient with an arteriovenous fistula is to: ( SELECT ONE THAT APPLY)

Correct Answer: D

Rationale: AV fistula care includes auscultating bruit (C) and palpating thrill (D) every 8 hours to confirm patency, not using it for draws (A).

Question 4 of 5

The nurse recognizes which statement is a potential ethical issue?

Correct Answer: B

Rationale: Questioning withdrawal of support (B) raises ethical concerns about autonomy and beneficence.

Question 5 of 5

Which finding on the ECG is most conclusive for infarction?

Correct Answer: A

Rationale: Pathological Q waves (A) indicate prior myocardial infarction due to necrosis.

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