Practice Question
A nurse has four clients who have all had a stroke. Which of the clients should the nurse see first?
Answer Choices:
Correct Answer:
An 80-year-old with sudden confusion
Rationale:
🌟 Sudden confusion in a stroke client is a priority change in neurologic status and may indicate re-stroke, hemorrhage, hypoxia, or metabolic disturbance.
🌟 Any acute alteration in mental status is treated as an urgent neurologic finding requiring immediate assessment (ABCs, vitals, neuro check).
🌟 In an older adult with a history of stroke, this could reflect cerebral edema, new ischemia, infection, or medication effects.
🌟 Early recognition and intervention can prevent further deterioration and may allow for time-sensitive treatments.
🌟 Therefore, this client is the highest priority among the four and should be seen first.
A 52-year-old with a history of smoking
🌟 A history of smoking is a significant risk factor for stroke and cardiovascular disease, but it does not represent an acute change in status.
🌟 The question is asking which client the nurse should see first, prioritizing current instability over chronic risk factors.
🌟 This client may need teaching and support for smoking cessation, but they are not described as having new neurologic symptoms.
🌟 Compared to sudden confusion, a smoking history alone is less urgent in terms of immediate nursing attention.
🌟 Thus, the client with a smoking history would not be seen before someone with an acute mental status change.
A 64-year-old who has dependent edema
🌟 Dependent edema suggests fluid overload, venous insufficiency, or heart failure, but it is typically a more chronic, non-emergent finding unless accompanied by severe respiratory compromise.
🌟 While it should be assessed and managed, it is not as critical as new neurologic changes like sudden confusion.
🌟 There is no indication here of acute distress, chest pain, or respiratory failure.
🌟 Edema requires evaluation but does not surpass the urgency of potential acute brain dysfunction.
🌟 Therefore, this client is not the first priority in this group.
A 75-year-old who needs to ambulate
🌟 A client who needs to ambulate after stroke likely requires assistance, safety measures, and possibly rehab support, but this is part of routine care.
🌟 There is no mention of acute neurologic deterioration, new deficits, or hemodynamic instability in this scenario.
🌟 Ambulation can typically be scheduled and supervised, unlike sudden confusion, which demands immediate evaluation.
🌟 Safety during ambulation is important, but it is not as urgent as possible re-stroke or acute cognitive change.
🌟 Thus, while important, this client should be seen after the one with sudden confusion.
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This question is from Examplify NR304 Quiz 3 BSNOL NOV25 which contains 10 questions.
More Questions from This Exam
Which of the following is not an anticipated finding for a client that experienced a stroke?
Answer Choices:
The nurse is assessing the client. Which findings are indicative of the need for further neurological assessment? (Select all that apply.)
Answer Choices:
Which outcome is most appropriate for a client being discharged to a long-term care facility after a stroke?
Answer Choices:
Which findings in this client's health history should the nurse associate with an increased risk for neurological impairment? (Select all that apply.)
Answer Choices:
Which of the following assessment findings can be related to chronic stress?
Answer Choices:
Question Details
- Category: RN Nursing Exam(s)
- Subcategory: Examplify Exam(s)
- Domain: Health Assessment
- Answer Choices: 4