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 B
Explanation
A. This option is not the most relevant for penile cancer detection. While swelling and ulcerated areas may be associated with various conditions affecting the scrotum, they are not specifically indicators of penile cancer. Penile cancer is more typically associated with changes in the penis itself rather than the scrotum.
B. Early signs of penile cancer may include a nodular or wart-like growth on the penis, especially on the glans (head) or shaft. These growths can be painless, making regular self-examination important for early detection. This statement demonstrates an understanding of one of the key indicators of penile cancer.
C. While penile discharge can indicate various conditions, including infections or sexually transmitted diseases, it is not a specific sign of penile cancer. This response does not reflect a direct understanding of the early detection of penile cancer.
D. Pain during urination can be caused by many conditions, such as infections or urinary tract issues, and is not a definitive sign of penile cancer. Additionally, many cases of penile cancer may not present with pain at all, particularly in the early stages.
Correct Answer is ["7"]
Explanation
(desired dose * volume of solution) / (concentration of drug * time) = rate.
For an infusion of 7 units per hour with a concentration of 100 units in 100 mL, the calculation would be: (7 units/hour * 100 mL) / (100 units * 1 hour) = 7 mL/hour.
Therefore, the nurse should set the IV pump to 7 mL per hour to deliver a continuous infusion of insulin at the prescribed rate.
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