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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Engage in a vigorous exercise program." This statement may not be suitable for a client with multiple sclerosis experiencing symptoms such as diplopia, dysmetria, and sensory changes. While exercise is beneficial for managing MS symptoms, it should be tailored to the individual's abilities and symptoms.
B. "Plan to relax in a hot tub spa each day." Hot tubs can exacerbate symptoms of multiple sclerosis, particularly heat sensitivity. Therefore, this statement is not appropriate for this client.
C. "Implement a schedule to include periods of rest." Fatigue is a common symptom of multiple sclerosis, and incorporating regular periods of rest into the daily schedule can help manage fatigue and conserve energy.
D. "Wear an eye patch on the right eye at all times." While wearing an eye patch may help alleviate diplopia (double vision), it is not typically recommended for continuous use and should be used under the guidance of an ophthalmologist or healthcare provider.
Correct Answer is D
Explanation
A. Therapeutic effects of medications may not be seen for 2-3 weeks: While it is important for the client to understand the timeline for therapeutic effects, ensuring medication adherence, especially during the initial period when therapeutic effects are not yet apparent, is of higher priority.
B. Physical dependency may result from extended use of medications: While the potential for physical dependency is an important consideration, ensuring medication compliance and adherence to the prescribed regimen, particularly in the context of managing seizures, takes precedence.
C. Urine may turn pink to brown but is not harmful: While this information may be included in the education plan to address potential side effects of antiepileptic medications, it is not the highest priority compared to ensuring the client understands the importance of taking medication regularly.
D. Take medication even if there is no seizure activity: Ensuring consistent medication adherence is crucial in managing seizure disorders to maintain therapeutic blood levels of antiepileptic medications and reduce the risk of breakthrough seizures. Missing doses can increase the risk of seizure recurrence.
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