what should a nurse assess in a patient presenting with symptoms of a stroke
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Nursing Elites

ATI LPN

ATI Comprehensive Predictor PN

1. What should a healthcare professional assess in a patient presenting with symptoms of a stroke?

Correct answer: A

Rationale: When assessing a patient with suspected stroke symptoms, it is crucial to check for facial drooping as it can be a sign of facial nerve weakness, which is a common indicator of stroke. While monitoring speech difficulties and evaluating arm weakness are also important assessments in stroke cases, they are secondary to facial drooping. Checking for the time of onset of symptoms is essential to determine eligibility for time-sensitive treatments like thrombolytic therapy, but when prioritizing assessments, facial drooping takes precedence.

2. A nurse is reviewing the plan of care for a client who is taking digoxin. Which of the following findings should the nurse monitor as an adverse effect of this medication?

Correct answer: A

Rationale: The correct answer is A: Hypokalemia. Hypokalemia is an adverse effect of digoxin. Digoxin can cause hypokalemia, which increases the risk of toxicity. Monitoring potassium levels is crucial when a client is taking digoxin. Choices B, C, and D are incorrect as hypernatremia, hypertension, and tachycardia are not directly associated with digoxin use.

3. A client with a serum albumin level of 3 g/dL has a pressure ulcer. What should the nurse do first?

Correct answer: B

Rationale: The correct first action for a client with a serum albumin level of 3 g/dL and a pressure ulcer is to consult a dietitian to improve the client's nutritional status. Adequate nutrition is essential for wound healing. Monitoring fluid and electrolyte balance is important but not the first priority in this situation. Administering a protein supplement can be considered after dietary evaluation. Administering an anti-inflammatory medication is not the primary intervention for addressing a pressure ulcer related to low albumin levels.

4. A client has a new diagnosis of Raynaud's disease. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The correct answer is to keep the home environment warm. Raynaud's disease causes vasospasm in response to cold, so maintaining a warm environment can help prevent attacks. Choices A, C, and D are incorrect. Increasing potassium intake, elevating legs when sitting, or reducing sodium intake are not specific to managing Raynaud's disease.

5. A client who is to undergo surgery for a hip fracture is being taught by a nurse about postoperative pain management. Which of the following statements by the client indicates an understanding of the teaching?

Correct answer: D

Rationale: The correct answer is D because taking pain medication at regular intervals helps maintain consistent pain control after surgery. Option A is incorrect because waiting for the pain to become unbearable can lead to inadequate pain management. Option B is incorrect as it suggests increasing medication without a schedule. Option C is incorrect because waiting for the pain to be severe before taking medication is not proactive pain management.

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