a nurse is assessing a client for signs of stroke which of the following should the nurse look for
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN

1. A healthcare professional is assessing a client for signs of stroke. Which of the following should the healthcare professional look for?

Correct answer: A

Rationale: Corrected Question: A healthcare professional is assessing a client for signs of stroke. Slurred speech is a common sign of stroke and should be assessed immediately. Choices B, C, and D are incorrect because increased appetite, elevated heart rate, and hyperactivity are not typical signs of a stroke.

2. A client at risk for coronary artery disease seeks advice from a nurse. What should the nurse recommend to reduce the risk?

Correct answer: B

Rationale: The correct recommendation to reduce the risk of coronary artery disease is to exercise for at least 150 minutes per week. Regular exercise is crucial in maintaining cardiovascular health and reducing the chances of developing heart disease. Increasing intake of saturated fats (Choice A) is counterproductive as it can raise cholesterol levels and contribute to arterial plaque formation. Taking iron supplements daily (Choice C) is not directly related to reducing the risk of coronary artery disease. Limiting fruits and vegetables in the diet (Choice D) is also not advisable, as they are essential components of a heart-healthy diet due to their high fiber and nutrient content.

3. A client just received the first dose of lisinopril. Which of the following is an appropriate nursing intervention?

Correct answer: C

Rationale: The correct answer is to provide standby assistance when getting out of bed. Lisinopril can cause first-dose hypotension, leading to dizziness and increasing the risk of falls. Standby assistance helps ensure the client's safety when mobilizing. Placing the client on cardiac monitoring (choice A) is not necessary unless there are specific indications for cardiac monitoring. Monitoring oxygen saturation (choice B) is not directly related to the side effects of lisinopril. Encouraging foods high in potassium (choice D) is not the most immediate or appropriate intervention following the administration of lisinopril.

4. A nurse is caring for a client with deep vein thrombosis (DVT). Which action should the nurse take?

Correct answer: D

Rationale: Withholding heparin IV infusion is the priority if there is a risk of complications such as bleeding, which must be evaluated before continuing treatment.

5. A nurse is caring for a client receiving corticosteroids. Which of the following should the nurse monitor?

Correct answer: D

Rationale: When a client is receiving corticosteroids, the nurse should monitor both blood glucose levels and blood pressure. Corticosteroids can elevate blood glucose levels, leading to hyperglycemia, and may cause hypertension. Monitoring these parameters is essential to detect and address any potential adverse effects promptly. While monitoring serum potassium levels is important in some situations, it is not a primary concern when caring for a client receiving corticosteroids. Therefore, choices A and B are the most appropriate options for monitoring in this scenario, making option D the correct answer.

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