Neurologic
A patient begins having a generalized tonic-clonic seizure. What is the nurse's priority action?
What is maintaining an airway?
A patient has sudden, severe pain and redness in the great toe. Which inflammatory disorder is most likely?
What is gout?
A patient with conjunctivitis asks how to prevent spreading the infection. What instruction should the nurse provide?
What is perform hand hygiene, avoid touching or rubbing the eyes, avoid sharing towels or cosmetics, and follow prescribed treatment?
A patient with HIV asks how antiretroviral therapy should be taken. What is the key teaching?
What is take antiretroviral medications consistently as prescribed and maintain follow-up for viral load, CD4 count, and treatment monitoring?
A patient with diabetes has abdominal pain, vomiting, deep rapid respirations, and a fruity breath odor. What emergency is likely?
What is diabetic ketoacidosis (DKA)?
A patient with a stroke suddenly develops facial drooping and unilateral arm weakness. What should the nurse do first?
What is activate the stroke response and determine the time the patient was last known well?
A patient with plantar fasciitis reports sharp heel pain with the first steps in the morning. What is an appropriate intervention?
What is plantar fascia and calf stretching, supportive footwear, activity modification, and prescribed pain management?
A patient with diabetes has progressive painless visual changes. Which complication should the nurse suspect?
What is diabetic retinopathy?
A patient with systemic lupus erythematosus reports new facial swelling and foamy urine. What complication should the nurse suspect?
What is lupus nephritis?
A patient with diabetes insipidus produces large amounts of dilute urine and has intense thirst. Which imbalance is the nurse concerned about?
What is a free-water deficit that can lead to dehydration and hypernatremia?
A patient with myasthenia gravis develops difficulty swallowing, a weak cough, and shallow respirations. What complication is the priority?
What is myasthenic crisis with impending respiratory failure?
A patient returns from total hip arthroplasty. Which nursing action is essential?
What is follow the specific surgical approach and postoperative hip precautions, assess circulation and sensation, manage pain, and mobilize safely as prescribed?
A patient reports severe ear pain after swimming. The external ear is tender when the tragus is moved. What is the likely disorder?
What is external otitis media?
A patient with HIV and a low CD4 count develops fever, shortness of breath, and a dry cough. What is the nursing priority?
What is urgent respiratory assessment and evaluation for opportunistic infection?
An older adult with type 2 diabetes presents with profound dehydration, altered mental status, very high glucose, and minimal ketones. What condition is most likely?
What is hyperglycemic hyperosmolar state (HHS)?
A patient with Guillain-Barré syndrome has ascending weakness. Which assessment finding requires immediate intervention?
What is declining respiratory function?
A patient with a suspected bone tumor reports persistent bone pain that worsens at night. What should the nurse prioritize?
What is prompt evaluation and diagnostic workup? Avoid assuming the pain is benign; anticipate imaging and biopsy as ordered, and protect a weakened bone from fracture.
A child has acute ear pain, fever, and a bulging tympanic membrane. What disorder does the nurse suspect?
What is acute otitis media?
A patient with lupus is prescribed hydroxychloroquine for long-term disease control. What ongoing monitoring is especially important?
What is regular ophthalmologic screening for retinal toxicity, along with medication-specific follow-up and symptom monitoring?
A patient being treated for DKA has a potassium level of 3.0 mEq/L before insulin infusion begins. What is the priority?
What is correct the hypokalemia before starting insulin, following the emergency protocol? Insulin shifts potassium into cells and can worsen hypokalemia, risking dangerous dysrhythmias.
A comatose patient has a declining level of consciousness, irregular respirations, and a newly dilated pupil. What is the priority concern?
What is worsening intracranial pressure or brain herniation?
A patient with a joint dislocation has a cool, pale extremity and absent distal pulse after injury. What is the priority?
What is an emergency neurovascular assessment and immediate escalation? Suspect compromised circulation; do not attempt an untrained reduction.
A patient with Ménière’s disease experiences sudden vertigo and nausea. What immediate nursing intervention helps reduce injury risk?
What is assist the patient to sit or lie down, maintain a safe environment, and institute fall precautions?
A patient with HIV has a CD4 count below 200 cells/mm³. What does this finding indicate?
What is advanced immunosuppression and increased risk for opportunistic infections?
A patient has a thyroid nodule, persistent hoarseness, and enlarged cervical lymph nodes. What should the nurse anticipate?
Correct response
What is further evaluation for thyroid malignancy, including appropriate imaging and tissue assessment?