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 D

Explanation

A. Obtain the client's heart rate: While obtaining the client's heart rate is important in the assessment of autonomic dysreflexia, assessing for and addressing the underlying cause take precedence.

B. Administer a nitrate antihypertensive: Administering antihypertensive medication may be necessary if autonomic dysreflexia is confirmed, but it is not the first action to take. Addressing the cause of autonomic dysreflexia, such as bladder distention, is the priority.

C. Place the client in a high-Fowler's position: Elevating the client's head may help reduce blood pressure, but it does not address the underlying cause of autonomic dysreflexia. Assessing for and addressing the cause, such as bladder distention, is the priority.

D. Assess the client for bladder distention: Autonomic dysreflexia is commonly triggered by stimuli below the level of spinal cord injury, such as bladder distention. Assessing the client's bladder for distention and addressing any urinary retention or obstruction is the first action to take in managing autonomic dysreflexia.

A. Apply an eye patch to the right eye. B. Teach the patient that the left visual deficit will resolve. C. Approach the patient from the right side. D. Place needed objects on the patient's left side.

Correct Answer is D

Explanation

A. Apply an eye patch to the right eye: Applying an eye patch to the right eye would further limit the patient's visual field, exacerbating the homonymous hemianopsia. This intervention is not appropriate for managing hemianopsia.

B. Teach the patient that the left visual deficit will resolve: Homonymous hemianopsia typically results from damage to the visual pathway in the brain and may not resolve completely. While visual rehabilitation techniques may help improve compensatory strategies, it is important to acknowledge and address the permanent nature of the deficit.

C. Approach the patient from the right side: Approaching the patient from the right side may startle them and increase the risk of falls or accidents due to the inability to perceive objects on their left side. The nurse should approach the patient from the unaffected side (the left side) to minimize the risk of injury.

D. Place needed objects on the patient's left side: Placing needed objects on the patient's left side helps compensate for the visual deficit by ensuring that essential items are within the patient's field of vision. This intervention promotes independence and safety for the patient with homonymous hemianopsia.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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