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

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

Assist with transport to a STAT non-contrast computed tomography scan of the head.

Perform a STAT EKG and assist with a STAT chest X-ray.

Notify the speech and language pathologist for a STAT dysphagia evaluation.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Administering recombinant tissue plasminogen activator (t-PA) may be necessary, but confirming ischemic stroke via CT scan precedes treatment to rule out hemorrhagic stroke, which contraindicates t-PA.

Choice B rationale

Performing a STAT non-contrast CT scan of the head is the priority to differentiate between ischemic and hemorrhagic stroke, enabling appropriate and timely intervention.

Choice C rationale

A STAT EKG and chest X-ray, though helpful in identifying concurrent cardiac or pulmonary issues, are not immediate priorities in acute stroke evaluation.

Choice D rationale

While assessing dysphagia is critical post-stroke, it is not a priority during initial stroke evaluation, which focuses on rapid imaging and differentiation of stroke type. .

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Correct Answer is B

Explanation

Choice A rationale

Fluid intake does not directly impact intraocular pressure. Management of glaucoma focuses on medications like eye drops and surgical interventions rather than restricting fluid intake.

Choice B rationale

Glaucoma treatments, including eye drops, aim to manage intraocular pressure. These medications are required lifelong to prevent optic nerve damage and preserve vision.

Choice C rationale

Excess salt impacts systemic blood pressure but does not directly influence intraocular pressure. Glaucoma management targets ocular pressure, not dietary sodium reduction.

Choice D rationale

Avoiding eye overuse may reduce strain but does not address intraocular pressure. Effective glaucoma treatment relies on pharmacological or surgical measures rather than activity limitation.

A. Kaposi's Sarcoma. B. Candidiasis stomatitis. C. Cryptosporidiosis. D. Meningitis.

Correct Answer is A

Explanation

Choice A rationale

Kaposi's Sarcoma is a vascular malignancy associated with AIDS caused by human herpesvirus 8. It presents as purple or brown skin lesions due to abnormal angiogenesis and endothelial proliferation in immunocompromised patients.

Choice B rationale

Candidiasis stomatitis typically manifests as white patches on the mucosa due to fungal overgrowth, not purple or brown spots. It is caused by Candida species, commonly seen in immunosuppressed individuals.

Choice C rationale

Cryptosporidiosis primarily leads to gastrointestinal symptoms such as watery diarrhea due to parasitic infection in AIDS patients, but does not cause purple or brown spots on the skin.

Choice D rationale

Meningitis causes inflammation of the meninges, leading to symptoms like headache, stiff neck, and fever. It does not present with purple or brown lesions on the skin.

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

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