Practice Question
A nurse in the emergency department is assessing a client who was brought in by a neighbor after falling down suddenly while walking. Which of the following assessments are the priority for the nurse to complete? (Select All that Apply.)
Answer Choices:
Correct Answer:
Muscle strength
Rationale:
🔷 Stroke suspicion: A client who collapses suddenly may be experiencing a cerebrovascular accident (CVA).
🔷 Muscle strength: Assess for unilateral weakness or paralysis.
🔷 Facial symmetry: Drooping is a key FAST (Face, Arm, Speech, Time) sign of stroke.
🔷 Vision changes: Sudden vision loss or double vision suggests neurological involvement.
🔷 Aphasia: Assess speech for slurring or difficulty forming words.
🔷 Peripheral pulses and smoking history are important later, but not immediate stroke assessments.
Want to practice more questions like this?
This question is from NUR 420 ADULT MS NURSING 11 TEST which contains 33 questions.
More Questions from This Exam
A nurse Is caring for a client who has spinal stenosis. Which of the following conditions should the nurse recognize as a risk factor for spinal stenosis?
Answer Choices:
A. Hyperthyroidism
B. Hysterectomy
C. Laminectomy
D. Chronic obstructive pulmonary disease
A nurse is providing medication teaching about sildenafil to a client who has erectile dysfunction. Which of the following statements is the nurse's highest priority?
Answer Choices:
A. "If you have an erection for more than four hours, seek emergency treatment.
B. "This medication does not prevent sexually transmitted infections."
C. "Take the medication before you plan to engage in sexual intercourse."
D. "This medication can cause a headache."
A client who has uncontrolled diabetes mellitus visits a clinic. Client reports numbness and tingling in the feet which keeps them up at night. The nurse explains this condition as a nerve disorder called peripheral neuropathy. Which of the following statements by the client indicates an understanding of what causes this condition?
Answer Choices:
A. "The nerve damage may occur for unknown reasons in any individual."
B. "The older i get, there is less blood flowing to my feet."
C. "The nerves just go to sleep when I lie down because no message gets from my brain to the spinal cord."
D. "The elevated blood sugar from my diabetes can cause underlying nerve damage."
A nurse is teaching a group of nursing students about spinal cord injuries in clients who are aged 65 years and older. Which of the following should the nurse identify as the most common cause of spinal cord injuries for this age group?
Answer Choices:
A. Falls
B. Sporting accidents
C. Motor vehicle accidents
D. Gunshot wounds
A family of a client who has a medical history of stroke, hyperlipidemia, and peptic ulcer disease arrives at the memory care clinic with concerns about their loved one. The family states that the client has experienced worsening memory loss and forgetfulness over the last 6 months. The nurse is concerned the client is experiencing vascular dementia, due to which of the following factors?
Answer Choices:
A. The client's history of stroke, because stroke can lead to dementia due to changes in the blood vessels of the brain.
B. The client's history of peptic ulcer disease, because peptic ulcer disease can lead to dementia due to the loss of nerve cells in the stomach.
C. The client's history of peptic ulcer disease, because peptic ulcer disease can lead to dementia by destroying neuron communication in the stomach.
D. The client's history of hyperlipidemia, because hyperlipidemia can lead to dementia due to blocked neuron communication throughout the body.
Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI MedSurg
- Answer Choices: 6
Was this question helpful?
0/5 average rating
(0 votes)