a client who has suffered a stroke is being assessed by the nurse what finding would indicate a complication
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Nursing Elites

HESI LPN

Adult Health 1 Final Exam

1. During the assessment of a client who has suffered a stroke, what finding would indicate a complication?

Correct answer: A

Rationale: Difficulty swallowing (dysphagia) can indicate complications such as aspiration risk, which is common after a stroke due to impaired swallowing reflexes. It poses a serious threat to the client's respiratory system. Options B, C, and D are less likely to indicate immediate complications post-stroke. A slight headache is a common complaint and may not necessarily indicate a complication. High blood pressure is a known risk factor for strokes but may not be an immediate post-stroke complication unless it is severely elevated. Muscle weakness on one side is a common sign of stroke but may not directly indicate a new complication.

2. The client with high blood pressure is being taught by the nurse to avoid adding salt during cooking. What effect does sodium have on blood pressure?

Correct answer: C

Rationale: The correct answer is C: 'It causes vasoconstriction of the blood vessels.' Sodium can lead to vasoconstriction, which narrows the blood vessels, increasing resistance to blood flow and subsequently raising blood pressure. Choices A, B, and D are incorrect. Sodium does not decrease blood viscosity, but it can lead to fluid retention, which increases blood volume and pressure. It does not enhance the excretion of potassium; instead, high sodium intake can lead to potassium excretion by the kidneys.

3. A client with a history of hypertension is admitted to the hospital for a suspected myocardial infarction. Which of the following is the priority nursing action?

Correct answer: B

Rationale: The priority nursing action in this scenario is to perform an ECG. An ECG is crucial in confirming myocardial infarction promptly and guiding immediate treatment decisions. Administering oxygen as prescribed is important but not the priority over confirming the diagnosis. Obtaining a detailed health history is relevant but does not take precedence over immediate diagnostic confirmation. While monitoring vital signs regularly is essential, performing an ECG is the priority action in this scenario to guide timely management.

4. The client with heart failure is prescribed furosemide (Lasix). What should the nurse include in the teaching plan?

Correct answer: A

Rationale: The correct answer is to instruct the client to increase potassium-rich foods in the diet. Furosemide is a loop diuretic that can cause potassium loss as a side effect. By increasing potassium-rich foods, the client can help prevent hypokalemia, a potential complication of furosemide therapy. Choice B is incorrect because while limiting sodium intake is generally advisable for heart failure, it is not directly related to furosemide use. Choice C is incorrect because fluid intake should be monitored and adjusted based on the individual's condition, but setting a specific limit of 1 liter per day is not a standard recommendation. Choice D is incorrect because furosemide is usually taken in the morning to prevent disturbances in sleep due to increased urination during the night.

5. During a bed bath, the nurse observes that a client's IV site is red and swollen. What should the nurse do first?

Correct answer: C

Rationale: The correct first action when a nurse observes a red and swollen IV site during a bed bath is to notify the physician. This is crucial because prompt reporting allows for immediate intervention to prevent further complications. Discontinuing the IV (Choice A) should only be done under the physician's guidance to avoid any adverse effects and ensure proper care. Applying a warm compress (Choice B) may not address the underlying issue and could potentially worsen the situation if the cause is an infection or infiltration. Documenting the site's appearance and continuing the bath (Choice D) without immediate action might delay necessary treatment, leading to potential complications.

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