What are the expected manifestations of a thrombotic stroke?

A. Gradual loss of function on one side of the body

B. Loss of sensation in the affected extremity

C. Sudden loss of consciousness

D. Seizures and convulsions

Correct Answer: A
Rationale: The correct answer is A: Gradual loss of function on one side of the body. Thrombotic strokes are caused by a clot forming in a blood vessel supplying the brain, leading to a gradual onset of symptoms due to impaired blood flow to specific brain regions. Choices B, C, and D are incorrect because loss of sensation, sudden loss of consciousness, seizures, and convulsions are not typically associated with thrombotic strokes. In a thrombotic stroke, the symptoms develop slowly over time, often over minutes to hours, and include manifestations such as weakness, numbness, or paralysis on one side of the body, along with other symptoms related to the affected brain area.

What should be monitored in a patient with diabetes insipidus?

• A. Monitor urine specific gravity for values below 1.005
• B. Monitor for increased thirst
• C. Monitor serum albumin levels
• D. Monitor blood pressure closely

Correct Answer: A
Rationale: In a patient with diabetes insipidus, monitoring urine specific gravity for values below 1.005 is crucial. Low urine specific gravity indicates excessive water loss, a key characteristic of diabetes insipidus. Monitoring for increased thirst (choice B) may be a symptom presented by the patient, but it does not directly reflect the condition's severity. Monitoring serum albumin levels (choice C) is not typically associated with diabetes insipidus. Monitoring blood pressure closely (choice D) is not a primary concern in diabetes insipidus unless severe dehydration leads to hypotension.

A nurse is admitting a client who has suspected appendicitis. Which of the following findings should the nurse report to the provider immediately?

• A. Distended, board-like abdomen
• B. WBC count of 15,000/mm3
• C. Rebound tenderness over McBurney's point
• D. Temperature of 37.3°C (99.1°F)

Correct Answer: A
Rationale: A distended, board-like abdomen should be reported to the provider immediately because it indicates peritonitis, a serious complication of appendicitis resulting from a ruptured appendix. Option B, an elevated WBC count, may indicate infection but is not as urgent as a board-like abdomen. Option C, rebound tenderness over McBurney's point, is a classic sign of appendicitis but does not indicate immediate life-threatening complications. Option D, a slightly elevated temperature, is not as concerning as a distended, board-like abdomen.

What teaching should be provided after cataract surgery?

• A. Avoid NSAIDs
• B. Wear dark glasses outdoors
• C. Creamy white drainage is normal
• D. Avoid bright lights

Correct Answer: A
Rationale: The correct teaching that should be provided after cataract surgery is to avoid NSAIDs. NSAIDs should be avoided to prevent bleeding, especially in the eye area. While wearing dark glasses outdoors is important to protect the eyes, it is not the most critical teaching after cataract surgery. Creamy white drainage being normal is not relevant to post-cataract surgery teaching. Avoiding bright lights is generally recommended for patients with certain eye conditions but is not a specific teaching point after cataract surgery.

What is the priority nursing intervention for a patient admitted with possible acute coronary syndrome?

• A. Administer sublingual nitroglycerin
• B. Obtain cardiac enzymes
• C. Get IV access
• D. Auscultate heart sounds

Correct Answer: A
Rationale: The correct answer is to administer sublingual nitroglycerin. This intervention is a priority for a patient with possible acute coronary syndrome because nitroglycerin helps vasodilate coronary arteries, increase blood flow to the heart muscle, relieve chest pain, and reduce cardiac workload. Obtaining cardiac enzymes (choice B) is important for diagnosing myocardial infarction but is not the initial priority. Getting IV access (choice C) is essential for medication administration and fluid resuscitation but is not the priority over administering nitroglycerin. Auscultating heart sounds (choice D) is a routine assessment but does not address the immediate need to relieve chest pain and improve blood flow to the heart in acute coronary syndrome.