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.
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. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Crossing the lower extremities and turning the hips and shoulders separately risks twisting or misalignment of the spinal column, which is contraindicated in spinal cord injury patients.
Choice B rationale
Asking the patient to assist by grasping the side rail is inappropriate as it may worsen the injury or result in unsafe movement, especially if the spinal cord is unstable.
Choice C rationale
Moving the patient independently with a draw sheet is unsafe due to the risk of misalignment or additional spinal damage, necessitating assistance and a coordinated approach.
Choice D rationale
Log rolling with one person holding the head and two others moving the body ensures spinal alignment and minimizes further injury during repositioning of spinal cord injury patients.
Correct Answer is D
Explanation
Choice A rationale
Squeezing the nurse’s hand on verbal request suggests neurological improvement and does not warrant urgent intervention, indicating preserved motor response and cognition.
Choice B rationale
Following commands with repetition/prompting shows mild cognitive delay or reduced processing but does not represent deterioration or life-threatening concern needing immediate action.
Choice C rationale
Purposeful movement to sternal rub implies intact motor response to noxious stimuli. It does not indicate significant neurologic worsening requiring urgent intervention.
Choice D rationale
Extending extremities in response to painful stimuli, known as decerebrate posturing, is a severe neurologic deficit indicating brainstem dysfunction and requires immediate nursing intervention.
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