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A client is admitted with a suspected stroke. Which is the nurse’s priority assessment?
A. Blood glucose level
✔✔ B. Time of symptom onset
C. Grip strength
D. History of hypertension
Which of the following is an expected finding in a client with left-sided stroke?
✔✔ A. Aphasia
B. Impulsive behavior
C. Left-sided neglect
D. Rapid speech
A client with a traumatic brain injury has clear fluid draining from the nose. What is the nurse’s
priority action?
A. Apply nasal packing
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,✔✔ B. Test the fluid for glucose
C. Suction the nose gently
D. Elevate the legs
Which of the following is an early sign of increased intracranial pressure?
✔✔ A. Restlessness
B. Decerebrate posturing
C. Dilated pupils
D. Bradycardia
A client with myasthenia gravis is at greatest risk for which of the following complications?
A. Renal failure
✔✔ B. Respiratory failure
C. Liver dysfunction
D. Stroke
Which of the following is a priority nursing intervention for a client during a generalized tonic-
clonic seizure?
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, A. Insert a tongue blade
B. Apply restraints
✔✔ C. Turn the client to the side
D. Provide water immediately after
What dietary instruction should the nurse provide to a client taking phenytoin?
✔✔ A. Maintain good oral hygiene and regular dental visits
B. Limit potassium-rich foods
C. Avoid dairy products
D. Increase vitamin K intake
Which finding is most concerning in a client with multiple sclerosis?
A. Muscle weakness
B. Numbness in extremities
✔✔ C. Difficulty swallowing
D. Fatigue
A client recovering from a stroke is coughing during meals. What is the nurse’s priority action?
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