A nurse is caring for a client who is unconscious following a stroke. Which of the following nursing interventions is of highest priority?
Monitor the client's electrolyte levels.
Perform passive range of motion on each extremity.
Suction saliva from the client's mouth.
Record the client's intake and output.
The Correct Answer is C
A. Monitoring electrolyte levels is important but is not as immediate as ensuring airway patency.
B. Performing passive range of motion is beneficial for mobility but does not address the immediate needs of an unconscious patient.
C. Suctioning saliva from the client's mouth is the highest priority intervention, as maintaining airway clearance is critical to prevent aspiration and ensure adequate ventilation.
D. Recording intake and output is necessary for overall assessment but is not as urgent as managing the airway.
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Correct Answer is C
Explanation
A. The headache is not related to anxiety but is a known side effect of nitroglycerin due to vasodilation.
B. An allergy to nitroglycerin typically presents as a rash or breathing difficulty, not a headache.
C. Nitroglycerin commonly causes headaches due to the dilation of blood vessels in the brain, which usually lessens over time as the body adjusts.
D. A headache does not indicate tolerance to the medication. Tolerance develops when the body becomes less responsive to the medication's effects, which usually involves a reduced effect on chest pain, not the onset of a headache.
Correct Answer is ["B","C","D"]
Explanation
A. Varicose veins are typically associated with venous insufficiency rather than coronary artery disease.
B. Chest pain, or angina, is a common symptom of coronary artery disease due to reduced blood flow to the heart muscle.
C. Palpitations can occur in clients with coronary artery disease as the heart compensates for decreased perfusion.
D. Shortness of breath can result from decreased cardiac output and oxygenation due to coronary artery disease.
E. A heart murmur is not a typical manifestation of coronary artery disease; it is more associated with valvular heart disease.