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 C

Explanation

Choice A rationale

Monitoring and documenting findings without intervention ignores the critical need to manage intracranial pressure (ICP). Normal ICP is 7-15 mmHg, and 25 mmHg indicates a dangerous elevation requiring prompt corrective actions.

Choice B rationale

Suctioning can trigger a vagal response, further increasing ICP. Interventions should aim to decrease ICP, not exacerbate it. Careful suctioning is used when airway clearance is critical, not as a routine measure.

Choice C rationale

Raising the head of the bed to 35–45 degrees promotes venous drainage, reducing ICP. Alerting the physician ensures timely medical interventions. This is the primary recommended action for elevated ICP cases.

Choice D rationale

Lowering the head of the bed can worsen ICP by impairing venous outflow. Padded side rails are useful for seizure precautions but are irrelevant for managing elevated ICP in this situation.

A. A patient who was in an assault resulting in basilar skull fracture. B. A patient who was found face down in water for an unknown length of time. C. A patient who suffered an epidural or subdural hematoma. D. A patient who experienced prolonged seizures without regaining consciousness.

Correct Answer is B

Explanation

Choice A rationale

Basilar skull fractures can lead to cerebral injuries and CSF leaks, but do not typically cause anoxic brain injury unless they compromise oxygenation or cause cerebral edema severely reducing blood flow.

Choice B rationale

Prolonged submersion compromises oxygen delivery, leading to diffuse cerebral hypoxia or anoxia, the primary cause of brain injury in drowning victims due to interruption of arterial oxygenation over unknown durations.

Choice C rationale

Epidural or subdural hematomas elevate intracranial pressure and compress brain tissue, but they are not as immediately hypoxic as situations involving complete oxygen deprivation like submersion.

Choice D rationale

Prolonged seizures, or status epilepticus, may disrupt normal metabolic processes, potentially causing neuronal injury. However, primary hypoxia is generally less pronounced than in submersion cases.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient in the ICU with a diagnosis of an acute closed head injury whose intracranial pressure (ICP) is 25 mmHg.What is the priority action by the nurse?

Correct Answer is C

Explanation

The nurse is caring for several patients in the Intensive Care Unit (ICU). Which of the following patients is at the greatest risk of anoxic brain injury?

Correct Answer is B

Explanation

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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?