A 78-year-old client is admitted to the Emergency Department (ED) with numbness and weakness of the right arm and slurred speech. Which nursing intervention is a priority?

Discuss the precipitating factors that caused the symptoms

Schedule a STAT computed tomography (CT) scan of the head

Prepare to administer recombinant tissue plasminogen activator (t-PA)

Notify the Speech Pathologist for an emergency consult

Answer and Explanation

The Correct Answer is B

A. While it's important to gather information about the client's symptoms, the priority in this situation is to determine the underlying cause of the neurological symptoms. A CT scan can quickly identify if there's been a stroke or other brain injury.
B. This is the most appropriate and urgent intervention. A CT scan can rapidly identify if the client has had a stroke, which is a time-sensitive medical emergency. Early diagnosis and treatment are crucial for minimizing brain damage and improving outcomes.
C. t-PA is a medication used to dissolve blood clots in the brain, but it is only effective if given within a specific time window after the onset of stroke symptoms. Without a confirmed diagnosis of stroke from a CT scan, administering t-PA could be harmful.
D. While a speech pathologist may be involved in the client's care later on, the priority is to determine the underlying cause of the neurological symptoms and initiate appropriate treatment. A CT scan is essential for this purpose.

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Correct Answer is D

Explanation

A. This statement is not advisable. While it is essential to avoid strenuous activity initially, gentle arm exercises and range-of-motion activities are generally encouraged as soon as possible to promote circulation and help prevent lymphedema. Immobilization can actually increase the risk of lymphedema.
B. This intervention is not recommended for preventing lymphedema. Sleeping on the side of the surgery (in this case, the left side) can put pressure on the affected arm and may not promote proper lymphatic drainage. Clients are often advised to sleep on their back or to position themselves in a way that does not compress the affected arm.
C. This intervention can provide temporary relief if there is swelling or discomfort, but it does not effectively prevent lymphedema. While cool compresses might help reduce inflammation, they are not a primary measure for lymphedema prevention.
D. This is the most effective intervention for preventing lymphedema. Elevating the affected arm helps facilitate lymphatic drainage and reduces the risk of fluid accumulation. Keeping the arm elevated above heart level encourages proper circulation and helps manage swelling.

A. Encourage the use of incentive spirometry B. report 8/10 incisional pain C. Assess popliteal pulses D. Early ambulation

Correct Answer is D

Explanation

A. This option is primarily aimed at promoting lung expansion and preventing atelectasis (collapse of the lung). While it's an important post-operative intervention, it does not directly reduce the risk of embolic events related to venous thromboembolism.
B. Reporting significant pain (8/10) may indicate complications such as infection or improper healing, but it does not directly relate to reducing the risk of embolic events. While managing pain is important for recovery, simply reporting it does not contribute to preventing VTEs.
C. Assessing popliteal pulses is part of a thorough circulatory assessment, but it mainly focuses on blood flow to the lower extremities rather than preventing embolic events. It can help identify existing DVT but does not actively reduce the risk of embolism.
D. This statement is true and is the best choice for decreasing the risk of an embolic event. Early ambulation promotes venous return, improves circulation, and significantly lowers the risk of DVT and pulmonary embolism in post-operative patients. Encouraging patients to get out of bed and move around as soon as they are stable is a key nursing intervention in post-operative care.

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A 78-year-old client is admitted to the Emergency Department (ED) with numbness and weakness of the right arm and slurred speech. Which nursing intervention is a priority?

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