CAT 1 DB
A client admitted with acute stroke suddenly becomes lethargic. Which action does the
nurse take next?
1. Notify the health care provider.2. Maintain the client's NPO. Examine for evidence of
infection. ANS-The correct response is 1. Prepare the patient for a CT scan. You responded
to 1. 1) PERFECT: In a patient who is experiencing an evolving stroke, sudden lethargy can
be a sign of an emergency or that the stroke may have gotten worse. The health care
provider should be immediately notified.
2) Although the client with acute stroke should take nothing by mouth because of the risk of
aspiration, this is not a priority action.
3) There is no reason to assess this client for signs of an infection.
4) It is unknown if a CT scan was performed as part of the stroke diagnostic workup. This
should not be done first. A client diagnosed with a small bowel obstruction vomits 300 mL of
dark brown emesis despite having a nasogastric tube set to low intermittent suction. The
nurse should take which action first. 1. Brush your teeth with a toothbrush. The client should
be in a semi-Fowler position. Examine the nasogastric tube's patency. Evaluate function of
suction equipment. - ANS-The correct answer is 2 . You answered 3.
1) Although comfort measures may help reduce further nausea and keep the oral mucosa
moistened, this is not the first action that the nurse should take.
2) CORRECT — Safety is a priority. Placing the client in a semi-Fowler position reduces the
risk of aspiration.
3) This may be a reason why the client vomited. Vomiting should not occur with a
nasogastric tube that is properly functioning; however, preventing aspiration is the priority.
4) This may be a reason why the client vomited. A nasogastric tube placed to suction
should prevent vomiting; however, preventing aspiration is the priority.
A client diagnosed with schizophrenia hears voices and tells the nurse that the building is
going to explode. Which action will the nurse take first?
1. Escort the client to a quiet room.2. Get the client to pay attention to the nurse. Provide
an emergency dose of medication.4. Call for help since the client is going to run. - ANS-The
correct answer is 2 . You answered 2.
1) Escorting the client to a quiet room may be necessary if the nurse is unable to orient the
client to reality, but this is not the first action to take.
2) CORRECT — The nurse needs to use a one-to-one approach and guide the client to
focus on the nurse instead of the hallucination.
3) An emergency dose of medication may be required, but this is not the first action to take.
4) Calling for help may be required if the situation escalates; however, this is not the first
action to take.
A client in her third trimester of pregnancy asks the nurse how to differentiate between true
labor and false labor. Which is the best explanation by the nurse to describe false labor to
the client?
1. The duration, frequency, and intensity of contractions remain the same2. Discomfort
begins in the back and radiates to the abdomen.3. Pink vaginal mucus is present during
A client admitted with acute stroke suddenly becomes lethargic. Which action does the
nurse take next?
1. Notify the health care provider.2. Maintain the client's NPO. Examine for evidence of
infection. ANS-The correct response is 1. Prepare the patient for a CT scan. You responded
to 1. 1) PERFECT: In a patient who is experiencing an evolving stroke, sudden lethargy can
be a sign of an emergency or that the stroke may have gotten worse. The health care
provider should be immediately notified.
2) Although the client with acute stroke should take nothing by mouth because of the risk of
aspiration, this is not a priority action.
3) There is no reason to assess this client for signs of an infection.
4) It is unknown if a CT scan was performed as part of the stroke diagnostic workup. This
should not be done first. A client diagnosed with a small bowel obstruction vomits 300 mL of
dark brown emesis despite having a nasogastric tube set to low intermittent suction. The
nurse should take which action first. 1. Brush your teeth with a toothbrush. The client should
be in a semi-Fowler position. Examine the nasogastric tube's patency. Evaluate function of
suction equipment. - ANS-The correct answer is 2 . You answered 3.
1) Although comfort measures may help reduce further nausea and keep the oral mucosa
moistened, this is not the first action that the nurse should take.
2) CORRECT — Safety is a priority. Placing the client in a semi-Fowler position reduces the
risk of aspiration.
3) This may be a reason why the client vomited. Vomiting should not occur with a
nasogastric tube that is properly functioning; however, preventing aspiration is the priority.
4) This may be a reason why the client vomited. A nasogastric tube placed to suction
should prevent vomiting; however, preventing aspiration is the priority.
A client diagnosed with schizophrenia hears voices and tells the nurse that the building is
going to explode. Which action will the nurse take first?
1. Escort the client to a quiet room.2. Get the client to pay attention to the nurse. Provide
an emergency dose of medication.4. Call for help since the client is going to run. - ANS-The
correct answer is 2 . You answered 2.
1) Escorting the client to a quiet room may be necessary if the nurse is unable to orient the
client to reality, but this is not the first action to take.
2) CORRECT — The nurse needs to use a one-to-one approach and guide the client to
focus on the nurse instead of the hallucination.
3) An emergency dose of medication may be required, but this is not the first action to take.
4) Calling for help may be required if the situation escalates; however, this is not the first
action to take.
A client in her third trimester of pregnancy asks the nurse how to differentiate between true
labor and false labor. Which is the best explanation by the nurse to describe false labor to
the client?
1. The duration, frequency, and intensity of contractions remain the same2. Discomfort
begins in the back and radiates to the abdomen.3. Pink vaginal mucus is present during
