A 70-year-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first?

Send the patient for a computed tomography (CT) scan.

Check the respiratory rate and effort.

Assess the Glasgow Coma Scale score.

Take the patient's blood pressure.

Answer and Explanation

The Correct Answer is B

A. Send the patient for a computed tomography (CT) scan: While obtaining a CT scan is important for diagnosing potential causes of the patient's left-sided hemiparesis, assessing the patient's respiratory status takes precedence to ensure adequate oxygenation and ventilation.

B. Check the respiratory rate and effort: Assessing the patient's respiratory rate and effort is the first priority to identify any signs of respiratory distress or compromise. Adequate oxygenation and ventilation are essential for maintaining vital organ function.

C. Assess the Glasgow Coma Scale score: While assessing the Glasgow Coma Scale score is important for evaluating the patient's level of consciousness and neurological status, it is not the first action to take in a patient with potential respiratory compromise.

D. Take the patient's blood pressure: While obtaining the patient's blood pressure is important for assessing hemodynamic stability, it is not the first priority when the patient presents with left-sided hemiparesis and may be at risk for respiratory compromise.

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Correct Answer is C

Explanation

A. “You might benefit from some psychological counseling." While psychological counseling may be helpful for coping with the emotional impact of epilepsy, it does not directly address the patient's concern about the possibility of having a seizure at work.

B. “The Department of Vocational Rehabilitation can help with work retraining." While
vocational rehabilitation services may be beneficial for individuals with disabilities, it may not directly address the patient's concern about continuing to work as a teacher.

C. "Epilepsy usually can be well controlled with medications." This response addresses the patient's concern by providing reassurance that epilepsy can often be effectively managed with medications. By effectively controlling seizures, the patient may be able to continue working without the fear of having a seizure at work.

D. “You will want to contact the Epilepsy Foundation for assistance." While the Epilepsy Foundation provides valuable resources and support for individuals with epilepsy, this response does not directly address the patient's concern about continuing to work.

A. Observe the client's ability to smile and frown. B. Instruct the client to look up and down without moving his head. C. Ask the client to shrug his shoulders against passive resistance. D. Have the client stand with eyes his closed and touch his nose.

Correct Answer is B

Explanation

A. Observe the client's ability to smile and frown: This assessment is related to cranial nerve VII (facial nerve), which controls facial expressions.
B. Instruct the client to look up and down without moving his head: Cranial nerve III (oculomotor nerve) controls eye movements, including upward and downward gaze. Asking the client to look up and down without moving the head assesses the function of this nerve.

C. Ask the client to shrug his shoulders against passive resistance: This assessment is related to cranial nerve XI (accessory nerve), which innervates the trapezius and sternocleidomastoid muscles involved in shoulder shrugging.

D. Have the client stand with eyes his closed and touch his nose: This assessment is part of the cerebellar function test and assesses coordination and proprioception but does not specifically assess cranial nerve III.

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A 70-year-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A high school teacher who has been diagnosed with epilepsy after having a generalized tonic- clonic seizure tells the nurse, "I cannot teach anymore. It will be too upsetting if I have a seizure at work." How should the nurse respond to specifically address the patient's concern?

Correct Answer is C

Explanation

A nurse is performing a neurological assessment for a client who has head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III?

Correct Answer is B

Explanation

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