A patient who just suffered a suspected ischemic stroke is brought to the ED by ambulance. On what should the nurse's primary assessment focus?
A) Cardiac and respiratory status
B) Seizure activity
C) Pain
D) Fluid and electrolyte balance
Ans: A
Feedback:
Acute care begins with managing ABCs. Patients may have difficulty keeping an open and clear airway secondary to decreased LOC. Neurologic assessment with close monitoring for signs of increased neurologic deficit and seizure activity occurs next. Fluid and electrolyte balance must be controlled carefully with the goal of adequate hydration to promote perfusion and decrease further brain activity.
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A nurse assisting a client to appraise perceived benefits of and barriers to taking a particular action for better health is applying principles of which one of the following theories or model?
a. Health Belief Model b. Protection Motivation Theory c. Theory of Planned Behavior d. Theory of Social Behavior
When the medication nurse offers a pill to the older adult patient, the patient asks, "What is this and what is it for?" What is the best response by the nurse?
a. "I'm not at liberty to discuss your medication. You need to talk to your doctor." b. "That's a ‘feel good' pill that will make you feel better." c. "It's a cephalosporin that has been ordered to treat your URI." d. "It's an antibiotic for the infection in your urine."
A nurse monitoring the intake and output of fluids for a client with severe diarrhea knows that normally how much body fluid is lost via the gastrointestinal tract?
A) 300 mL B) 1,000 mL C) 1,300 mL D) 2,600 mL