the nurse reports that a client is at risk for a brain attack stroke based on which assessment finding
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Nursing Elites

HESI LPN

Medical Surgical HESI 2023

1. The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding?

Correct answer: B

Rationale: The correct answer is B: Carotid bruit. A carotid bruit is a significant risk factor for stroke as it indicates turbulent blood flow due to narrowing of the carotid artery. Nuchal rigidity is associated with meningitis, jugular vein distention can be a sign of heart failure, and palpable cervical lymph nodes may indicate infection, but they are not directly linked to stroke risk.

2. A client with hyperthyroidism is prescribed methimazole. Which adverse effect should the nurse monitor for?

Correct answer: A

Rationale: The correct answer is Agranulocytosis. Methimazole, used to treat hyperthyroidism, can lead to agranulocytosis, a severe decrease in white blood cells. This condition increases the risk of infections and requires immediate medical attention. Hypoglycemia (choice B) is not a common adverse effect of methimazole. Bradycardia (choice C) is unlikely as methimazole tends to have minimal effects on heart rate. Hypercalcemia (choice D) is not associated with methimazole use.

3. Which laboratory results should the nurse anticipate to be abnormal in a child with hemophilia?

Correct answer: D

Rationale: In a child with hemophilia, the nurse should anticipate an abnormality in the partial thromboplastin time (PTT) due to the deficiency in clotting factors. Prothrombin time, bleeding time, and platelet count are typically normal in hemophilia. Prothrombin time measures the extrinsic pathway of coagulation and is not affected in hemophilia. Bleeding time assesses platelet function, which is normal in hemophilia as the issue lies with clotting proteins, not platelets. Platelet count is also expected to be normal unless there is another underlying condition affecting platelet production or function.

4. What is a priority action for the nurse when caring for a client with suspected meningitis?

Correct answer: B

Rationale: Administering intravenous antibiotics is the priority when caring for a client with suspected meningitis. The prompt administration of antibiotics is crucial to treat bacterial meningitis and prevent potential complications. Isolating the client in a private room may be necessary to prevent the spread of infection, but antibiotic administration takes precedence. Obtaining a throat culture and performing a chest x-ray are important diagnostic measures, but they do not address the immediate need for antibiotic therapy in suspected bacterial meningitis.

5. The client with osteoporosis is being taught about dietary modifications by the nurse. Which food should the nurse recommend to increase calcium intake?

Correct answer: A

Rationale: Broccoli is the correct answer as it is a good source of calcium, which is essential for clients with osteoporosis. Broccoli is a green leafy vegetable that provides a significant amount of calcium. Chicken breast, white bread, and apple do not contain as much calcium as broccoli and therefore are not the best choices to recommend for increasing calcium intake in clients with osteoporosis.

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