AACN PCCN Prep Online

Unilateral neglect is an inattention to stimuli on one side, most commonly after a stroke. Nursing care focuses on increasing awareness and attention to the neglected side through environmental setup and cueing. The choice describing placing commonly used items on the neglected side and reminding the patient to turn the head and scan toward that side promotes active attention and use, which supports neurologic rehabilitation. Encouraging use of only the unaffected side can worsen inattention to the neglected side. Performing all tasks for the patient limits practice and functional recovery. Avoiding interaction on the neglected side does not retrain attention and may reinforce neglect.

ECG changes in hyperkalemia (such as peaked T waves and QRS widening) indicate increased risk of malignant dysrhythmias. The most urgent first step is cardiac membrane stabilization with intravenous calcium gluconate, which rapidly antagonizes the membrane effects of potassium and lowers the immediate arrhythmic risk. The choices mentioning an “intravenous infusion of dextrose and insulin” and “nebulized albuterol” can help shift potassium into cells and lower the serum potassium concentration, but they do not provide the immediate membrane-stabilizing effect needed when ECG changes are present. The choice mentioning “oral sodium polystyrene sulfonate” lowers potassium via gastrointestinal elimination but has a delayed onset and is not appropriate as the most urgent initial intervention in this setting.

ST-segment elevation in leads II, III, and aVF is consistent with an acute inferior STEMI, most commonly due to acute coronary thrombosis. Early administration of aspirin is a priority because it rapidly inhibits platelet aggregation and has a well-established mortality benefit when given as soon as possible in suspected acute myocardial infarction (if no contraindications such as true aspirin allergy or active major bleeding). Clopidogrel is also an antiplatelet agent used in acute coronary syndromes (often in combination with aspirin), but aspirin is the immediate first-line antiplatelet in initial management. Atorvastatin is important early in ACS care (high-intensity statin therapy), but it does not address the immediate platelet-driven thrombotic process with the same priority as aspirin in initial treatment. Lisinopril (an ACE inhibitor) may be started after stabilization in appropriate patients, but it is not the first medication to administer during the initial management of acute STEMI.