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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The elevated pH and decreased PaCO2 indicate that the respiratory system is causing alkalosis, typically due to hyperventilation (excessive breathing).
B. Metabolic alkalosis would be indicated by a high pH with a normal or high HCO3. Since the HCO3 level is normal and the PaCO2 is low, this does not fit the picture of metabolic alkalosis.
C. Respiratory acidosis would be characterized by a low pH and an elevated PaCO2 due to inadequate ventilation and accumulation of carbon dioxide. Here, the pH is high, and the PaCO2 is low.
D. Metabolic acidosis would be indicated by a low pH with a low HCO3. In this case, the pH is high, and the HCO3 is normal.
Correct Answer is C
Explanation
A. This is not an appropriate action as it can increase pressure on the bladder and worsen the spasms.
B. While warming the irrigation solution can help to prevent discomfort, it is not the most effective way to address the bladder spasms.
C. Belladonna and opium suppositories are commonly used to relieve bladder spasms. They work by relaxing the muscles in the bladder and reducing pain. In a client who has undergone TURBT and is experiencing continuous bladder irrigation, these suppositories can be an effective way to manage discomfort.
D. Meperidine is a narcotic pain reliever that can be used to manage pain after surgery. However, it is not specifically indicated for bladder spasms and may not be the most appropriate medication in this case.
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