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. .

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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.

A. Hemiparesis of the right side of the body and ataxia. B. Spasticity of the client's left arm and apraxia. C. Impulsive behavior and hostility toward family. D. Homonymous hemianopia and diplopia.

Correct Answer is A

Explanation

Choice A rationale

Hemiparesis on the right side and ataxia are common manifestations of left-sided stroke, where the motor cortex affecting the contralateral side is impaired, leading to muscle weakness and coordination loss.

Choice B rationale

Spasticity of the left arm suggests motor impairment on the ipsilateral side, which is inconsistent with the nature of left-sided strokes affecting the contralateral side. Apraxia lacks relation to motor loss here.

Choice C rationale

Impulsive behavior and hostility are more indicative of frontal lobe involvement, not motor loss secondary to left-sided strokes. These behaviors do not represent motor manifestations.

Choice D rationale

Visual defects like homonymous hemianopia and diplopia may occur in stroke but are not direct indicators of motor loss. They relate to occipital lobe or optic pathway damage.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

The nurse is preparing to turn the patient who sustained a spinal cord injury.How should the nurse proceed?

Correct Answer is D

Explanation

A nurse is assessing a client experiencing motor loss as the result of a left-sided stroke.Which clinical manifestations would the nurse document?

Correct Answer is A

Explanation

The nurse is educating on the placement of a ventriculostomy (intraventricular catheter) to the family of a patient diagnosed with a brain injury.The nurse states, "The ventriculostomy is placed:

When considering the pharmacologic management of a patient who has sustained a traumatic head injury, the nurse can anticipate an order for which of the following medications to manage increases in intracranial pressure (ICP)?

A client presents to the emergency department actively having seizure activity.The paramedics report the client has a history of epilepsy but her family doesn't know the names of her current medications.The priority for this patient is:

The nurse is caring for a trauma patient with a suspected brain injury and Battle's Sign.The nurse notices a yellow stain around fluid dripping from the patient's ear.The nurse's priority intervention will be as follows:

The nurse is caring for a patient diagnosed with a traumatic head injury secondary to a work accident.In the morning assessment, the patient opened his eyes in response to noxious stimuli.Two hours later, what assessment finding would warrant immediate action by the nurse? The patient:

The nurse is developing a teaching plan for the client with glaucoma.Which of the following instructions would the nurse include in the plan of care?

A client with a severe stroke has been prescribed enteral feedings via a jejunostomy tube.For safe administration, the nurse should:

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?