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. Limiting fluids with meals is not a recommended practice for preventing prostatitis. Staying hydrated is generally encouraged to promote urinary health. This option does not address the prevention of prostatitis recurrence.
B. This is a good instruction. Frequent voiding helps reduce the risk of urinary stasis and potential bacterial growth in the urinary tract, which can contribute to prostatitis. Encouraging the client to empty their bladder regularly is beneficial in preventing recurrence.
C. While monitoring PSA levels can be important for assessing prostate health, it is not a direct preventive measure for prostatitis recurrence. PSA tests are primarily used to screen for prostate cancer or monitor prostate conditions rather than prevent prostatitis itself.
D. This recommendation is not appropriate for preventing prostatitis. While caffeine may irritate the bladder and prostate, decaffeinated drinks typically do not have the same effect and can be a good source of hydration. Avoiding decaffeinated drinks does not contribute to prostatitis prevention.
Correct Answer is A
Explanation
A. Ascites is a condition where excess fluid accumulates in the abdominal cavity. It is a common finding in advanced-stage ovarian cancer as the cancer can spread to the abdominal organs and lymph nodes, leading to fluid buildup.
B. Chest pressure is not a typical symptom of advanced-stage ovarian cancer. It might be associated with other conditions, such as heart disease or lung problems.
C. Painful urination is not a common symptom of advanced-stage ovarian cancer. It might be associated with other conditions, such as urinary tract infections or bladder problems.
D. Excessive flatus is not a typical symptom of advanced-stage ovarian cancer. It might be associated with other gastrointestinal conditions.
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