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 A

Explanation

Choice A rationale

Metoprolol decreases cardiac workload by reducing heart rate and myocardial oxygen demand. A heart rate of 62 is within normal limits, demonstrating effective beta-blocker action and improved cardiac efficiency.

Choice B rationale

Lying flat without difficulty breathing reflects improved respiratory status, which is more related to pulmonary management, not directly indicative of reduced cardiac workload or beta-blocker efficacy.

Choice C rationale

Absence of dyspnea after climbing stairs suggests improved physical fitness but does not directly measure the cardiac effects of metoprolol, which targets heart rate reduction and myocardial oxygen use.

Choice D rationale

Weight loss is related to overall health improvement or dietary changes rather than specific effects of metoprolol, which primarily impacts heart rate and cardiac oxygen consumption.

A. Obtain a blood specimen to check for serum drug levels. B. Administer lorazepam IV to stop the convulsive activity. C. Check the client's blood pressure and heart rate.

Correct Answer is B

Explanation

Choice A rationale

Checking serum drug levels provides insight into compliance and effectiveness but doesn’t address immediate seizure cessation, prioritizing treatment over diagnostic assessment.

Choice B rationale

Administering lorazepam IV halts seizure activity quickly by enhancing GABA activity, calming neuronal excitation, and stabilizing the patient’s condition, reducing potential complications.

Choice C rationale

Monitoring vitals like blood pressure and heart rate is essential but doesn’t directly address convulsive activity, which requires immediate pharmacological intervention to prevent status epilepticus progression. .

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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

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Correct Answer is A

Explanation

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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?