What is the priority action for a client who presents with symptoms of stroke?

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Question 1 of 5

What is the priority action for a client who presents with symptoms of stroke?

Correct Answer: A

Rationale: The correct answer is A: Perform a CT scan. This is the priority action because it helps determine if the stroke is ischemic or hemorrhagic, guiding treatment decisions. Monitoring blood pressure (B) is important but not the priority. Administering aspirin (C) can be considered after confirming the type of stroke. Administering thrombolytics (D) is indicated for ischemic stroke but should only be done after ruling out hemorrhagic stroke with a CT scan.

Question 2 of 5

A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems?

Correct Answer: A

Rationale: The correct answer is A: Breathing, pain, sleep. Prioritizing breathing is crucial as it is a life-threatening issue. Pain should be addressed next to ensure the patient's comfort and well-being. Sleep can be addressed last as it is a lower priority compared to breathing and pain. Prioritizing in this order ensures the patient's immediate needs are met first. Choice B is incorrect because sleep should not take precedence over pain when the patient is in acute pain. Choice C is incorrect because addressing sleep before breathing and pain can be detrimental to the patient's health. Choice D is incorrect because breathing should be the top priority over both pain and sleep.

Question 3 of 5

A patient is at the clinic to have her blood pressure checkeShe has been coming to the clinic weekly since her medications were changed 2 months ago. The nurse should:

Correct Answer: A

Rationale: Rationale: 1. Collecting a follow-up database ensures up-to-date information. 2. It allows for monitoring of medication effectiveness and any new symptoms. 3. Checking the blood pressure is essential but needs current context. 4. Asking the patient to read her record may not provide all necessary updates. 5. The complete health history is crucial but obtaining it first may delay urgent blood pressure check.

Question 4 of 5

A 59-year-old patient tells the nurse that he is in the clinic to "check up on his ulcerative colitis." He has been having "black stools" in the last 24 hours. How would the nurse document his reason for seeking care?

Correct Answer: D

Rationale: The correct answer is D because it accurately reflects the patient's chief complaint of having black stools in the last 24 hours, which is a concerning symptom suggestive of gastrointestinal bleeding. This documentation is specific and focused on the reason for seeking care, prioritizing the urgent nature of the symptom. Choice A is incorrect because it does not mention the presenting symptom of black stools. Choice B is incorrect as it does not directly state the reason for seeking care. Choice C is incorrect as it focuses on the patient's self-diagnosis of ulcerative colitis rather than the current concerning symptom of black stools.

Question 5 of 5

In response to a question about use of alcohol, a patient asks the nurse why the nurse needs that information. What reason would the nurse give the patient?

Correct Answer: B

Rationale: The correct answer is B because alcohol can interact with medications and exacerbate certain medical conditions. The nurse needs this information to ensure the patient's safety and well-being. Choice A is incorrect because the question is not about the patient's reliability. Choice C is incorrect as it assumes the nurse is required to educate the patient about alcohol dangers. Choice D is incorrect because even without an obvious drinking problem, alcohol use can still impact the patient's health.

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